iraqi journal of hematology vol.5 issue 1 2016

Transcription

Iraqi Journal of Hematology(IJH)
IJH is a Peer Reviewed Scientific biannual Medical Journal published by the
National Center of Hematology Al-Mustansiriyah University, Baghdad-Iraq.
May 2016
Volume 5, Issue 1
Editor director
Editor-in-chief
Prof. Dr.Ali Muhammed Jawad FRCP
Prof.Dr. Alaa Fadhil Alwan FICMS
Secretary
Dr.Nidhal Kareem Alrahhal MSc, D.CH
Executive editorial Board
Prof.Dr.Raad Jaber Musa FICMS
Advisory board
Prof.Dr. Naseer Al-Allawi Ph.D (univ.Dohuk)
Prof.Dr.Ban Abass Abdulmajid PhD
Prof.Dr. Khalid Nafee CABM (univ.Mosul)
Prof.Dr.Salma Abass Alhadad CABM
Prof.Dr. Ali Muslim CABM (USA,Ohaio)
Assist.Prof.Dr.Aladin M.Zubair FICMS
Prof.Dr. Ahmed Ibraheem M.D (lebanon)
Assist.Prof.Dr.Alaadin S.Naji FICMS
Prof.Dr.Anwar Sheikha FRCP(univ.sulaymani)
Prof.Dr.Mead Kadhim CABM(Univ.Basrah)
Prof.Dr.Subh S. Al-Modalal FICMS(nahrain)
Prof.Dr.Waseem Fadhil CABM.(univ.Nahrain)
Dr.Jaafar Alghaban consultant CABM
Ass.Prof. Adeeb abbas PhD(Uni.mustansiriya)
Ass. Prof. Nabil Salman CABM (Egypt)
First issue published in 2011
Ass. Prof. Raheem Mahdi FICMS(univ.Kufa)
1st editor-in-chief Dr.Nabil S. Murad
Ass.prof.Alaa Sadik Alawad(Univ.Babylon)
1st editor director Dr. Adeeb Alshami
Ass. Prof. Mazin Faisal FICMS(univ.baghdad)
Ass. Prof.Haitham AlRubai FICMS(Baghdad)
Ass. Prof. Ahmed Kudhair FICMS(univ.Erbil)
Dr. Fatin Al-Yassin (Bagdad teach.Hosp)
Dr.Bassam Francis FICMS(Bagh.Teach.Hosp.)
Dr.Asad A. Eledan FICMS(Basrah Teach. Hos)
Dr.Ibrahim K. Ibrahim CABM(Kadhimin Hos)
Dr Abdulmajeed Alwan CABM(Yarmouk Hos)
Dear doctors and colleagues
We would like to congratulate all the colleagues specially those who
work in hematology field, clinical and laboratory for publishing volume 5
issue 1 of the Iraqi Journal of hematology. This issue contains 10 original
articles deal with different topics concerning hematological diseases. We
sincerely hope from the authors to continue their support and cooperation
through sending original articles, case reports, scientific comments and
criticism to the editors in order to keep the journal going on and to keep
raising its standards.
Kind regards
Editor in chief
Instructions to Authors
Editor Director
Prof.Dr.Ali Muhammed Jawad
FRCP,CABM
Editor in-chief
Prof. Dr.Alaa Fadhil Alwan
FICMS jnt med, FICMS clin hem
Secretary
Dr. Nidhal K. Al-Rahhal
M.S.C. (Physiology)-D.CH
Executive Editorial Board
Prof. Dr.Raad Jaber Mosa
M.Sc,FICMS(hempath)
Prof.Dr. Ban Abbas Abdulmajid
Ph.D Molecular path
Prof.Dr.Salma Abass AlHadad
CABM ped
Ass.Prof.Dr.Alaadin Mudafar
FICMS(hempath)
Ass.Prof.DrAladdin Sahham Naji
FICMS jnt med, FICMS clin hem
The Iraqi Journal of Hematology is a
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Center of Hematology in collaboration
with the Iraqi Society of Hematology.
The journal welcomes original articles,
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Table of Contents
Title
Inducing of Interleukins -10 and 8 by Epstein Barr Virus in Chronic Lymphocyte
Page
1
Leukemia………………… Luma Amer Yassir ,Amer Alnajjarr, Dawood S. Dawood
,Alaa Fadhil Alwan
Immunohistochemical expression of VEGF in relation to VEGFR and CD34 in
NHL using digital image analysis system………..
19
Bassam Mohammad Hameed,
Hind Shaker Al-Mamoori, Raad Jaber Musa
Evaluation of the changes in iron homeostasis and hepcidin concentration in
32
preeclamptic patients…………Noora Abd Ali Muhsin, Subuh Salim Al-Mudalal
The results analysis of complete blood count during the first half of 2015 at the
42
Central Child Teaching Hospital in Baghdad………………. Rasha Tariq Jawad ,
Ebtehal Ali Hussien
Distribution of red cell antigens according to ABO, Rh and other rare blood
55
group systems in Kurdish ethnicity…………….Hisham A. Getta, Shaema S.Amin,
Najmaddin Khoshnaw , Belal A. Muhammad
Review of Congenital Factor XIII Deficiency in Single Iraqi Teaching Hospital
81
Lubna Foad Hussain, Obeida Amir Abid
CD38 and ZAP-70 as prognostic immunological parameters In patients with
90
chronic lymphocytic leukemia…………..… Intisar Sh. Ali ,Ghassan A.Al-Anni
,Salman A. Al-Jubury
Evaluation the Role of Bone Marrow Examination in Diagnosis of Hematological
98
Diseases in Hemato-Oncology Centers in Kurdistan Region……….Shorsh Jameel
Ridha , Nawsherwan Sadiq Mohammad , Hoger Ismael Muhammed Sarhang
Types of Anaemia in Patients with Rheumatoid Arthritis in Sulaymaniyah-
114
Kurdistan Region of Iraq……………. Hisham A. Getta, Najmaddin Khoshnaw ,
Alaa Fadhil Alwan ,Sundus F.A, Raouf R. Mirza
A Clinical-Hematological Study of Pancytopenia Patients Attending Nanakaly
Hospital in Erbil City………… Alan Isaac Isho , Nawsherwan Sadiq Mohammad,
Saran Abdulqadir Nooruldin
129
Original article
Inducing of Interleukins-10 and 8 by Epstein Barr Virus in Chronic
Lymphocytic Leukemia
Luma A. Yassir 1, Amer Alnajjar2, Dawood S. Dawood 3, Alaa Fadhil Alwan 4
1 MSc microbiology/ The national center of hematology/Almustansiriya University/ Baghdad/Iraq
2 Prof. of medical virology/ head Dept. of microbiology / Almustansiriya medical college/Baghdad/Iraq
3 Assistant prof. of medical virology/ Dean of medical technical college/Baghdad / Iraq
4 Prof. of clinical hematology/ director of national center of hematology/Baghdad/ Iraq
Received: 2/12 /2015
Accepted: 14/ 12/ 2015
Abstract:
Background: Many newer studies reported that Epstein- Barr virus (EBV) has
association with chronic lymphocytic leukemia (CLL). The average age of presentation is
of patients with CLL is between 65 and 70 years with male to female ratio is 2:1. Notably,
several studies have reported that expression of Epstein Barr encoding RNA (EBERs) is
associated with progressive or accelerated clinical courses. This type of RNA increases
the level of IL-8 and IL-10 in serum of newly diagnosis of CLL patients.
Objectives: the aims of study were to determine the interleukins 10 and 8 level in newly
diagnosed CLL patients and determine the incidence of EBV infection in patient of CLL.
Materials and Methods: A prospective study conducted at department of clinical
hematology in the national center of hematology in Baghdad, Iraq from January 2013 to
January 2014. It included thirty samples of formalin-fixed, paraffin-embedded tissue of
bone marrow aspirates samples and blood from newly diagnosis B-CLL. They were
diagnosed with CLL according to Binet criteria. The detection of EBV encoded RNAs
(EBER1, EBER2) and also detection for the level of Interleukin (8 and 10) in the serum of
CLL patients were done by in situ hybridization technique.
Results: Histopathological study revealed that all the controls were negative for EBERs
and 46.7% were found to be EBERs positive. There was a correlation between positive
EBERs and tumors stage and also EBERs and IL-10 and with IL-8.
Conclusion: The highest incidence of CLL occurs in the age group 40-80 years old and
males are more liable than females (male/female: 70/30).In situ hybridization technique is
successful method to detect of EBV and positive EBERs. IL-8 is highly significant in
CLL patients and correlates with EBERs and LMP1. There is a correlation between IL-10
EBERs and LMP1 in CLL patients.
Keywords: Epstein-Barr virus, CLL, EBERs, IL-8, IL-10
Iraqi J. Hematology, May 2016, vol.5, Issue 1
1
Inducing of Interleukins -10 and 8 by Epstein Barr
Luma A.Y., Amer A., Dawood S. D., Alaa F.A.
Introduction
Chronic lymphocytic leukemia (CLL)
regularly
results from neoplastic proliferation of a
immortalized after exposure to EBV,
mature B
although this can be achieved after
dividing
by the accumulation of nonSmall
characterized
lymphocytes.
by
a
It
is
persistent
lymphocytosis of more than 10 x 109/
liter and lymphoid intrusion of the bone
marrow of at least 40% (1,2)
With the use of immunological markers,
it is likely to establish the diagnosis of
CLL by B cell clonality, even with
lymphocyte counts of less than 5 x
109/liter. CLL is documented as a disease
entity in the WHO organization and as
the
leukemic
counterpart
of
small
activated
or
cytokine activation.(4)
Epstein-Barr virus is the first virus
described to be linked with the human
pathogenesis
of
tumor.
The
topographical distribution of Burkitt
lymphoma were related to areas endemic
with falciparum malaria is supposed to
cause chronic excitement or suppression
of the immune system, making children
more susceptible to the oncogenicity of
EBV.(5,6)
In 1968, EBV was recognized to be
lymphocytic lymphoma and CLL the
most common type of adult leukemia in
become
the
etiological
factor
of
infectious
(3)
mononucleosis. At the same time, EBV
the
was reported to alter infected B cells to
immunoglobulin heavy chain variable
uncontrolled proliferation.(7) A large study
region (Ig VH) genes can differentiate
in 2009 determined around one in every ten
between these two groups: CLL patients
stomach cancers contained EBV. Studies are
with unmutated immunoglobulin high
ongoing to decode what role the virus is
the United States and Western Europe.
The
mutation
status
of
variable (Ig VH) genes have a negative
prognosis with rapid progression of the
disease.(3)
playing in this type of cancer and how it
weaves together with other risk factors like
nutrition, genetics, and infection of H.
pylori.(8)
Epstein- Barr virus (EBV) infection is
only occasionally detected in CLL by
Initiation of EBV lytic program occurs in
conventional diagnostic approaches. This
memory B cells recirculating during the
is consistent
lymphoid
with in vitro results
suggesting that CLL cells do not
tissue
related
with
the
oropharyngeal mucosa. Host
2
immunosuppression may also
Material and Methods:
generate
viral reactivation in lately infected B
cells, which leads to creative infection.
Nevertheless, the original mechanism of
viral reactivation in vivo is not clearly
understood.(9)
EBV
alters
causing
This study was designed as a prospective
(case-control) study conducted on the
following main groups during the period
from January 2013 to January
Thirty
B-lymphocyte
formalin-fixed,
2014.
paraffin
growth,
embedded tissue blocks were obtained
growth
from Bone marrow biopsies and blood
permanent
transformation by regulated expression
samples of B-CLL patients.
of multiple viral genes. These genes
The age of the patients ranged between
comprise
40-80 years, and the
three
integral
membrane
proteins, latent membrane proteins 1,
collected
2A, and 2B (LMP), 6 EBV nuclear
Baghdad Teaching Hospital,
antigens (EBNA1, 2, 3A, 3B, 3C, and
National Center of Hematology and
EBNA-LP), then two small, non-coding
Twenty Bone marrow biopsies and blood
nuclear RNAs (EBERs). The gene linked
sera
products relate with or present homology
hematological problem other than CLL
to
as control.
various
cytokines,
endorsing
antiapoptotic
and
signal
EBV
molecules,
transducers,
infection,
immortalization, and alteration.(10)
EBV-1 and EBV-2, which vary depend
the EBV nuclear antigen (EBNA)
genes.(11) .EBV-1 is more common in
most populations and is more competent
in transforming B cells in vitro. EBV-2
is mainly found in parts of Africa and is
related endemic Burkitt lymphoma.
of
20
from patients
patients
in
from the
who
have
We use In situ hybridization to detected
EBERs in Bone marrow samples In situ
hybridization detection kit from abcam
There are two types of EBV viruses ,
on
directly
samples were
(12)
lot-S01_M61, REF _ WB. 005.50:
Hybridization / detection system for
EBV was purchased from ZytoFast
/Germany Cat. Numbers (T-1070-40)
and ELISA kit for detection Human
IL-10
and
Il-8
by
(abcam46059
lot:GR162207- 4) and (abcam46032 the
lot: GR151489-6) .
3
Results:
significantly
The distribution of age in the studied
group ranged between 40 - 80 years with
a mean of (60.4) year (table 4.1). Males
constituted 70% of cases and female
30%. The ages of control groups ranged
between 42 - 70 years with a mean of
(55.8) year. Males constituted 76.2% of
control groups and female constituted
23.8%. (Table 1).
As shown in table (2), all controls were
negative for EBERs. Although the
median score and intensity for EBERs
was negative for cases group, the mean
rank for EBERs score, intensity and
composite score (a score resulting from
multiplying the score by intensity) was
higher
among
cases
compared to controls, figure (1),(2) ,(3)
and Figure( 4 ) show the result of In situ
hybridization. As shown in table (3), the
median IL8 was significantly higher in
CLL cases group (33.1 pg/ml) compared
to control group (22.1 pg/ml),also in
figure (5).
A similar
pattern was
applicable to IL10. The median IL10 was
also significantly higher in CLL cases
group (29.1 pg/ml) compared to control
group (0 pg/ml), figure (6) . As shown in
table (4), the positive test for EBERs
had no obvious or statistically significant
association with IL8 concentration. IL10
concentration also failed to show any
noticeable
linear
correlation
with
similarly measured IL8 concentration.
Table (1): CLL patients distribution according the age and gender
Age (years)
Gender
<50
50--60--=>70
Mean±SD(Range
)
P value
Male
Female
P value
CLL
Control
No
%
5
16.7
7
23.3
14
46.7
4
13.3
60.4±9.2 (40-80)
No
%
4
19.0
9
42.9
7
33.3
1
4.8
55.8±8.1 (42-70)
0.392
21
9
70.0
30.0
16
5
76.2
23.8
0.626
.
*Significant difference between proportions using Pearson Chi-square test at 0.05 level
4
Table 2 : The case-control difference in median score and intensity and composite
score for EBERs viral marker.
Study group
Controls
Cases (CLL)
N
%
N
%
P
1. EBERs-score
Negative
20
100.0
16
53.3
+
0
0.0
11
36.7
++
0
0.0
3
10.0
Total
20
100.0
30
100.0
(Negative to
Range
Negative)
(Negative to ++)
<0.001
Median
Negative
Negative
(Negative to
Inter-quartile range
Negative)
(Negative to +)
Mean rank
18.5
30.2
2. EBERs-intensity
Negative
Weak
Moderate
High
Total
Range
Median
Mean rank
<0.001
20
100.0
0
0.0
0
0.0
0
0.0
20
100.0
(Negative to
Negative)
Negative
(Negative to
Negative)
18.5
16
8
5
1
30
53.3
26.7
16.7
3.3
100.0
(Negative to High)
Negative
(Negative to weak)
30.2
EBERs-composite score (score x
3. intensity)
Range
Median
Mean rank
<0.001
(Negative to
Negative)
Negative
(Negative to
Negative)
18.5
(Negative to 6)
Negative
(Negative to 1)
30.2
5
Relative frequency (%)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0
10
36.7
++
+
Negative
100
53.3
Controls
Cases (CLL)
Figure 1: Component bar chart showing the case-control difference in EBERs-score.
100%
0
90%
3.3
16.7
Relative frequency (%)
80%
70%
26.7
60%
50%
High
Moderate
Weak
Negative
100
40%
30%
53.3
20%
10%
0%
Controls
Cases (CLL)
Figure 2: Component bar chart showing the case-control difference in EBERsintensity.
6
6
5
4
3
2
1
0
Controls
Cases (CLL)
Study group
Figure 3 : Dot diagram with error bars showing the median (with its inter-quartile
range) EBERSs in cases with CLL compared to controls.
7
a
b
: Representative expression of EBV-encoded small nuclear early
region (EBERs) in Bone Marrow of CLL patients d . a : positive result
show the Nuclear localization of the EBERs in neoplastic cells by ISH . b :
Negative result.
Figure 4
8
Table 3 : The case-control difference in median interleukin concentration.
Study group
Controls
Cases (CLL)
IL8 (pg/ml)
Range
Median
N
Mean rank
(12.2 - 55.3)
22.1
(17.9 - 35.4)
41
20.6
IL10 (pg/ml)
Range
Median
N
Mean rank
P
0.03
(7.8 - 1215)
33.1
(21.9 - 70.1)
30
29.8
<0.001
(0 - 24.9)
0
(0 - 0)
41
12
(0.9 - 43)
29.1
(7.7 - 33.9)
30
35.8
10000
IL8
1000
100
10
1
Controls
Cases (CLL)
Study group
range) IL8 (pg/ml) in cases with CLL compared to controls. (Logarithmic scale was
used)
9
45
40
35
IL10
30
25
20
15
10
5
0
Controls
Cases (CLL)
Study group
range) IL10 (pg/ml) in cases with CLL compared to controls.
Table 4 : The median IL8 concentration (pg/ml) by selected explanatory variables
among cases with CLL.
Range
IL8
Interquartile
Median
range
N
Mean
Rank
Age group
(years)
<60
60+
(10.6 to 79.4)
(7.8 to 1215)
31.9
36
(22.2 to 61.3)
(21.9 to 130.3)
12
18
14.5
16.2
Gender
Female
Male
(7.8 to 1215)
(10.6 to 346.2)
55.6
32.8
(20 to 401.5)
(24.3 to 46.9)
9
21
17.2
14.8
Positive EBERs
Negative
Positive
P
0.6[NS]
0.5[NS]
0.1[NS]
(10.6 to 1215)
(7.8 to 401.5)
43.1
30.4
(25.3 to 104.9)
(17.7 to 44.4)
16
14
18
12.7
10
Table 5 : The median IL10 concentration (pg/ml) by selected explanatory variables
among cases with CLL.
IL10
Interquartile
Median
range
Range
Age group (years)
<60
(0.9 to 38.3)
60+
(2.5 to 43)
Positive EBERs
Negative
Positive
20.35
32.3
(6.25 to 29.85)
(9.3 to 34.8)
N
Mean
Rank
12
18
12.9
17.3
P
0.18[NS]
0.63[NS]
(0.9 to 43)
(2.2 to 43)
20.75
32.3
(8.5 to 33.9)
(4 to 33.9)
16
14
14.8
16.3
Discussion :
Epstein-
Barr
virus
has
strong
association with variety in B-cell tumors
including Burkitt's lymphoma, Hodgkin
lymphoma, human immunodeficiency
virus, post transplantation lymphoma
disorder
and
chronic
However EBERs is also found in
quiescent EBV latency where no protein
is
produced
and
that
may
be
a
suboptimal marker for proliferation or
transformation capability.
lymphocytic
leukemia. Many studies reported that
In this study all controls showed
CLL patient had evidence of EBV
negative result EBERs but in patients the
infection by In situ hybridization for
result show that 14 (46%) out of 30 CLL
EBERs and detection of EBV-encoded
patients were positive with EBERs.
EBER transcripts is considered the gold
standard for localizing latent EBV in
tissue samples, as EBER transcripts are
universally
expressed
in
all
EBV
associated tumors.(13,14)
Results obtained are nearly compatible
to previous study who reported that
(38%) of CLL patients had evidence of
EBV infection
proved by EBERs
positively in tumor cells (16).
The presence of EBERs has been shown
or
Result demonstrated in this study were in
accelerated clinical course including
accordance with 16) Tsimberidou et al
transformation to Richter's large cell
who stated that 12 out of 32 CLL
lymphoma.(15,16)
patients has appositive result.(16)
to
correlate
with
progressive
11
On the other hand another study found
In our study we found that IL-8 was
that
8 of 75 (10.7%) cases showed
significantly higher in CLL cases group
EBERs expression restricted to 5–10%
the compared with control group. This
of tumor cells.
(17)
result is compatible with other study
This controversy in the above results
may be related to that ISH process
depends on the RNA staining and the
concentration of RNA in the cell .this
method
affected
by
many
factors,
including the RNA present in the cell
and
concentration
of
RNA.
This
technique is very sensitive. Interleukins8 and it's receptor increased in cancer
published
(23,24)
which found that plasma
IL-8 level enhances in CLL patients. The
same result was studied by Yoshizaki et al
who found that IL-8 increased in CLL
patients .(25) On the other hand another
study found that serum IL-8 level was not
increased in significant level in patient
with CLL when she compared with
healthy control.(26)
cells, infiltrating neutrophils, endothelial
The association of EBERs and IL-8 did
cells,
not
and
tumor-associated
macrophages (18)
by normal B cells but many studies
showed that the natural cellular source
of IL-8 production have been described
to be monocyte/macrophages, T cells,
large granular lymphocytes, fibroblasts,
cells,
mesothelial
cells,
keratinocytes, neutrophils ,hepatocytes
and chondrocytes.(19,20,21)
al showed that elevated IL-8 levels may
be founds in the serum of untreated B
cell patient which may be release by B
cells and superannuated of purified Bcells
contain
level
This
of
statistical
result
is
not
compatible with study done by William
et al who found that the stages were
associated
with
significantly
higher
plasma IL-8 levels (P < 0.0001) but
There were no significant difference
between IL-8 production and gender.
(27)
While another study found compatible
result with this study where IL8 level in
CLL patients not correlated with CLL
stages. (24)
A study which has been done by Celle et
CLL
the
significance.
There is no evidence of IL-8 production
endothelial
reach
IL8
released
chemotactic activity for neutrophils. (22)
Notably,
serum
IL-10
levels
are
increased in CLL patients and correlate
with adverse disease features and short
survival.(28,29)
Results obtained in this study revealed
that the IL-10 was significantly higher in
CLL cases group median rang (29.1 pg.
12
/ml) compared to control group (0 pg/ml)
new approach for the treatment of B-
and the mean rank 35.8 with p<0.001
CLL.(33,34)
figure (6)
IL-10 was derived from EBV infected
This result is compatible with other
tumor cells and demonstrated in serum
study(30),Which found that IL-10 levels
of CLL and Hodgkin lymphoma patients.
were higher in CLL patients (median,
(30,34)
5.04 pg/mL; range, undetectable to 74
association between EBERs, LMP1and
pg/mL)
IL10
than
normal
volunteers
undetectable;
range,
enhanced production of viral IL-10 and
undetectable to 13.68 pg/mL) (P <
may also contribute to a local immune
.00001) ,and another study found that IL-
suppression
10 levels increased in CLL patient of
hydrophobic peptides derived from the
Iraq and significantly than control group
first transmembrane domain of LMP-1
P<0.05 same study was studied by [31]
(35)
who found that Serum levels IL-10 in 20
transcription
CLL patient
depending
(median,
in
. Several studies have reported an
severely dropped in
untreated
group
(27±11.47
and
0.65±0.23
pg/mL
respectively)
and
differed significantly
stimulation.
EBV
by
infection
production
of
In contract EBERs induce the
of
on
various
cell
type,
cytokines
such
as
interleukin-10 (IL-10).
healthy in 20
Conclusion: The highest incidence of
control group (1715.66±1014 pg/mL
CLL occurs in the age group 40-80 years
respectively)
(26)
and David at al
who
old and males are more liable than
found that Serum IL-10 levels were also
females (male/female: 70/30).In situ
significantly elevated in
hybridization technique is successful
CLL
patients. (18)
method to detect of EBV and positive
Other explanations for the increase in
EBERs. IL-8 is highly significant in CLL
the level of IL-10 in patient with CLL
patients and correlates with EBERs and
was demonstrated in other researches
LMP1. There is a correlation between
which found that
IL-10 EBERs and LMP1 in CLL
IL-10 is increased in
production by culture of CLL and that
patients.
serum IL-10 levels were elevated in five
of the eleven B-CLL patients. These
findings suggest that IL-10 acts as an
autocrine growth factor for B-CLL cells
and cytokine-based therapy might be a
13
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Evidence of Constitutive Interleukin-8
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R, Wakisaka N et al. Induction of
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Interleukin-8
et al. Interleukin-6 and interleukin-10
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Virus
Latent Membrane Protein-1 and Its
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32.Kitabayashi A., Kirokawa M., Miura
(2).
A.B . The role of interleukin-10 (IL-10)
with
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lymphocytic
in chronic B-lymphocytic leukemia: ILIraqi J. Hematology, May 2016, vol.5, Issue 1
16
10
Exprazession
prevents
leukemic
cells
from
of
the
Transcription
apoptotic cell death. Int J Hematology.
Factors ATF-2/c-Jun in B Lymphocytes
.(1995 ;62:99-106.
but not in B-CLL Cells Virus Genes
33.Tangye S.G., Weston K.M., Raison
,(2005); 30:3, 323–330.
R.L .Interleukin- 10 nhibits the in vitro
35.Naji A. S. Outcome of 49 Iraqi adult
proliferation
patients
leukemic
of
CD51
human
activated
B-cells.
Leuk
with
Chronic
Lymphocytic
Leukemia treated with oral alkylating
Lymphoma. .(1998) ;31:121-130.
agent:, J Fac Med Baghdad. (2012); 54
34.Blay J.Y., Voorzanger N., Favrot M.,
(2).
Burdin N., Rousset F., Banchereau J.
Presence of Epstein-Barr virus viral
interleukin 10 in the serum of patients
with
non-human-immunodeficiency-
Correspondance to
Luma Amer MSc.
virus related diffuse large-cell nonHodgkin’s lymphomas. Blood. (1995).
86:4702-4704.
Dept. of molecular genetic
The national center of hematology
34.Bandobashi K. , Liu A. , Mi Nagy N.
et
al
.EBV
Infection
Induces
Almustansiriyah university
17
‫‪Luma A.Y., Amer A., Dawood S. D., Alaa F.A.‬‬
‫‪Inducing of Interleukins -10 and 8 by Epstein Barr‬‬
‫تحفير االنترلوكين‪ 01-‬و ‪ 8‬بواسطة فيروس ابشتاين بار في سرطان الدم الليمفاوي المزمن‬
‫لمى عامر ياسر ‪ ،0‬عامر النجار ‪ ، 2‬داود سلمان داود ‪ ، 3‬عالء فاضل علوان ‪4‬‬
‫‪ 1‬ماجستير علم األحياء المجهربة ‪ /‬المركز الوطني ألمراض الدم ‪ /‬الجامعة المستنصرية ‪ /‬بغداد ‪ /‬العراق‬
‫‪ 2‬أستاذ علم الفيروسات الطبية ‪ /‬رئيس قسم األحياء المجهربة ‪ /‬كلية طب المستنصرية ‪ /‬بغداد ‪ /‬العراق‬
‫‪ 3‬استاذ مساعد‪ .‬علم الفيروسات الطبية ‪ /‬عميد كلية التقنية الطبية ‪ /‬بغداد ‪ /‬العراق‬
‫‪ 4‬أستاذ أمراض الدم السريرية ‪ /‬مدير المركز الوطني لألمراض الدم ‪ /‬بغداد ‪ /‬العراق‬
‫الملخص‪:‬‬
‫الخلفية‪ :‬اثبت الدراسات ان االبيشتاين بار فايرس له عالقة ويعتبر احد المسببات لمرضى سرطان‬
‫الدم اللمفاوي المزمن في هذه الدراسة كان معدل عمر المرضى يتراوح بين (‪ )56-07‬عام وكانت‬
‫نسبة الذكور الى االناث تتراوح بين ‪ % 1/2‬في مرضى سرطان الدم اللمفاوي المزمن وكما اثبت‬
‫هذه الدراسة ان ‪ EBERs‬يزيد من افراز ‪ IL-10‬و‪ IL-8‬في مصول المرضى ‪.‬‬
‫المواد والطرق ‪ :‬دراسة مستقبلية أجريت في قسم علم أمراض الدم السريري في المركز الوطني‬
‫لألمراض الدم في بغداد‪ ،‬العراق خالل الفترة من يناير ‪ 3102‬إلى يناير ‪ .3102‬وشملت ثالثين‬
‫عينات من واألنسجة الثابتة بالفورمالين جزءا ال يتجزأ من البارافين من عينات نخاع العظام والدم‬
‫من حديثي التشخيص ب سرطان الدم اللمفاوي المزمن ‪ ..‬وقد أجريت للكشف عن الرنا ‪EBV‬‬
‫المشفرة (‪ ،)EBER2 ،EBER1‬وكذلك الكشف عن مستوى انترلوكين (‪ 8‬و ‪ )01‬في مصل‬
‫الموقعي‪.‬‬
‫التهجين‬
‫بتقنية‬
‫المزمن‬
‫اللمفاوي‬
‫الدم‬
‫سرطان‬
‫مرضى‬
‫النتائج ‪ :‬كشفت الدراسة النسيجية أن جميع الضوابط كانت سلبية ‪ EBERs‬ووجد ‪٪2..4‬‬
‫إيجابية من ‪ EBERs‬في سرطان الدم اللمفاوي المزمن ‪ .‬كان هناك ارتباط بين ‪ EBERs‬اإليجابية‬
‫‪.IL-8‬‬
‫مع‬
‫و‬
‫‪IL-10‬‬
‫و‬
‫‪EBERs‬‬
‫وأيضا‬
‫األورام‬
‫ومرحلة‬
‫االستنتاج‪ :‬يحدث أعلى معدل النتشار سرطان الدم اللمفاوي المزمن في الفئة العمرية ‪ 81-21‬سنة‬
‫والذكور أكثر عرضة من اإلناث (ذكور ‪ /‬إناث‪ . )21/41 :‬تقنية التهجين الموقي هي طريقة‬
‫ناجحة للكشف عن ‪ EBV‬و‪ EBERs‬اإليجابية‪ IL-8 .‬مهم للغاية في المرضى الذين يعانون من‬
‫سرطان الدم اللمفاوي المزمن ويرتبط ‪ EBERs‬و‪ .LMP1‬هناك عالقة بين ‪EBERs IL-10‬‬
‫المزمن‪.‬‬
‫اللمفاوي‬
‫الدم‬
‫سرطان‬
‫مرضى‬
‫في‬
‫و‪LMP1‬‬
‫كلمات البحث‪ :‬فيروس ابشتاين بار‪ ،‬سرطان الدم اللمفاوي المزمن ‪IL-10 ،IL-8 ،‬‬
‫‪18‬‬
‫‪Iraqi J. Hematology, May 2016, vol.5, Issue 1‬‬
Original article
Immunohistochemical expression of VEGF in relation to VEGFR and
CD34 in NHL using digital image analysis system
Bassam Mohammad Hameed1, Hind Shaker Aboob2, Raad Jaber Musa3
1 M.B.Ch.B., Msc. Pathology (haematology), Ph.D. Pathology (haematology) Lecturer at Department of
pathology and forensic medicine /collage of medicine /AL-Nahrain university
2 M.B.Ch.B., FIBMS(path/haemaology) Lecturer at Department of pathology and forensic medicine /collage of
medicine /AL-Nahrain university
3 M.B.Ch.B., M. Sc. Path. (Haem.); F.I.C.M.S.Path.(Haem.) Professor of Haematology at Department of
Received 31/12/2015
accepted 15/2/2016
Abstract
Background: Lymphoma growth and progression appear to be promoted by at least two distinct
angiogenic mechanisms: autocrine stimulation of tumor cells via expression of Vascular Endothelial
Growth Factor(VEGF) and Vascular Endothelial Growth Factor Receptor(VEGFR) by lymphoma
cells, and paracrine influences of the proangiogenic tumor microenvironment on local tumor
vascularity.
Objectives: To assess autocrine effect of VEGF, by studying the correlation of VEGF expression
with its receptor VEGFR expression in NHL. And to assess paracrine effect of VEGF, by studying the
correlation of VEGF expression with CD34 expressed on endothelial cells in Non-Hodgkin
Lymphoma (NHL).
Materials and Methods: A cross sectional study was designed. A total of 66 bone marrow tissue
samples were included in the study, all diagnosed as having NHL according to working formulation.
From each block, 3 sections were taken, and were immunohistochemically stained for CD-34, VEGF
and VEGFR. Scoring of Immunohistochemical staining was performed using specialized automated
cellular image analysis system, Digimizer software, version 3.7.0.
Results: VEGF Immunohistochemical digital parameters named digital labeling index (DLI) was
significantly correlated with the followings; VEGFR (DLI) [P =0.042, r =0.324], CD34 stained area
(A) [P=0.037, r =0.556]. Also VEGFR (DLI) was significantly correlated with CD34 (A).
Conclusion: Autocrine and paracrine effect of VEGF is evident in NHL, as there is positive
correlation between VEGF expression and VEGFR expression, and as tumor vascularity increase with
the increase in VEGF expression.
Keywords: NHL, VEGF, VEGFR
19
Immunohistochemical expression of VEGF
Bassam M.Hameed, Hind Sh. Aboob, Raad J. Musa
Introduction
quantification while overcoming manual
Tumor angiogenesis mediated by many
mediators in tumor microenviroment, of
these VEGF (vascular endothelial growth
scoring method that requires considerable
expertise
and
is
interobserver variability.
susceptible
to
(4)
Aims of the study
factor) is the most important factor for
angiogenic switch through its interaction
with receptors regulating different aspects
of tumor angiogenesis. Lymphoma growth
and progression as many other tumor
promoted by angiogenesis, this occurs by
two
main
mechanisms;
autocrine
stimulation of tumor cells by expressing
both VEGF and its receptor VEGFR, and
second by paracrine influences of the proangiogenic tumor microenvironment. (1)
Many researchers stated that there is
positive
expression
correlation
with
between
studying
the
correlation
of
VEGF
expression with its receptor VEGFR
expression, in bone marrow biopsy of nonHodgkin
lymphoma
patient
using
automated image analysis system.
2. To assess paracrine effect of VEGF, by
studying
the
correlation
of
VEGF
expression with CD34 expressed on
endothelial cells, in bone marrow biopsy
of non-Hodgkin lymphoma patient using
automated image analysis system.
Materials and methods
expression
A cross sectional study was designed, a
in DLBCL lymphoma cells supporting the
total of 66 tissue samples (paraffin block
concept of autocrine-paracrine role for
of bone marrow biopsy) were included in
VEGF as growth factor for DLBCL
the study. All the samples were taken from
promoting
the (Medical city/ teaching laboratories),
cell
VEFGR
VEGF
1. To assess autocrine effect of VEGF, by
survival
and
proliferation.(2,3)
cases presented during the period 2008-
In this study we tried to study angiogenesis
via VEGF, VEGFR and microvessel
density in non-Hodgkin lymphoma using
digital analysis system, Advantages of
using digital image system in that scoring
immunohistochemical staining
in this
method offer objectivity, reproducibility,
2010 as all diagnosed having NHL
according to working formulation by
histopathological examination for primary
lymph node biopsy. From each block, 3
sections of 5µm thickness were taken,
each section were immunohistochemically
stained for CD-34, VEGF and VEGFR.
20
The procedure was carried out according
immunostaining intensity was done by
to manufacturer's instructions. Taking
using the Magic Wand tool in the toolbar
sections and mounted on Fisher brand
menu in digimizer program (see figure 1).
positively charged slides. Than slides
The tolerance level of the Magic Wand
deparaffinized, and placed in DAKO
tools was adjusted so that the entire
antigen retrieval (PH 6 for VEGF, PH 9
positive
for VEGFR, 1700 for CD34) after heating
measurements comprised:
slides with antigen retrieval solution in
microwave for 20 min, slides let to cool
down. Later on LSAP (DAKO staining kit)
used
for
staining,
after
blocking
endogenous peroxidase, and incubation of
primary antibody for 30 min. Scoring of
immunohistochemical
staining
was
performed using specialized automated
cellular image analysis system, Digimizer
software, version 3.7.0.
a
were
selected.
The
1. Color Intensity (I): which measures the
average intensity of the brown color for
the selected objects depending on the
expression of antigens in the cells.
2. Fractional area stained (A) = [(mean
area× Number of objects) / area of a single
image field]
100%
3. Digital Labeling Index (DLI): first used
by Al-Sinjery, G. M. [5], this tool is
calculated according to the following
Image capture
Using
cells
formula:
light
microscope,
each
DLI=
[Fractional
area(A)
×
reverse
immunohistochemically stained slide was
Intensity(I)].
scanned with 10 × objectives for the
This
positive brown immunostaining, and with
representative for the expression because it
40× objective three fields that reflect the
combines both the Fractional area and the
best of the overall immunostaining of the
Intensity
entire slide were chosen and captured
staining.
using a Sony digital camera (cyber-shot
DSC-W510).
Captured
images
of
digital
parameter,
of
is
the
best
immunohistochemical
Statistical analysis:
4000×3000 pixels were saved on PC in an
Statistical analysis was performed with
uncompressed JPG format.
SPSS
Image analysis
(statistical
package
for
social
sciences) version 16 and Excel 2007
programs.
Each image was analyzed by Digimizer
software (Version 3.7.0). Determination of
21
Figure 1. showing snap shot for digimizer softwear window
Results
Correlation between digital parameters of
correlated with the followings; VEGFR
digimizer softwear of VEGF and other
digital
angiogenic markers in NHL: Digital
staining area (A), as well as VEGFR (DLI)
parameter for VEGF digital labeling index
was significantly correlated with the CD34
(DLI) which combines staining intensity
staining area (A). figure (II)
labelling
index
(DLI),
CD34
and area staining was significantly
22
y = 0.553x + 21.406
120
VEGF DLI
100
80
60
40
20
0
0
20
40
60
80
100
120
VEGFR DLI
Figure II. Correlation chart shows positive correlation between VEGF (DLI) and VEGFR1(DLI),(P =0.042, r =0.324).
140
y = 0.9586x + 13.552
120
VEGF DLI
100
80
60
40
20
0
0
10
20
30
40
50
60
CD34 area
Figure III. Correlation chart shows positive correlation between VEGF (DLI) and CD34
(A),(P=0.037, r =0.556).
23
120
100
VGEFR DLI
80
y = 1.1056x - 1.5145
60
40
20
0
0
10
20
-20
30
40
50
60
CD34 area
Figure IV. Correlation chart shows positive correlation between VEGFR-1 (DLI) and
CD34(A),(P=0.041, r = 0.303).
Figure V. Trephine biopsy section from a patient with Folliculer lymphoma showing
paratrabecular infiltration& random focal . H&E, x 4 objective.
24
Figure VI. Trephine biopsy section from a patient with B-SLL showing nodular
infiltration . with D20 + immunohistochemistry (X 4 objective.).
Figure VII. Trephine biopsy section from a patient with B-DLL showing diffuse
infiltration. With CD20 + immunohistochemistry (X 10 objective.)
25
Figure VIII. Trephine biopsy section from a patient with B-DLL stained with
immunohstochemistry showing positive VEGF-A lymphoma cells (arrows). With
cytoplasmic brown staining (40X).
26
Figure IX. Trephine biopsy section from a patient with B-DLL showing endothelial cells
positive for CD34 stained with immunohstochemistry (40X).
Discussion
In
Iraq
digimizer software for CD34+ blood
many
researchers
studied
angiogenesis in different malignancies like
prostate
adenocarcinoma,
multiple
myeloma , renal cell carcinoma, gastric
adenocarcinoma.(6-9) Kareem and Jaafer
studied angiogenesis in haematolymphoid
tumors, Kareem studied MVD in NHL,
while Jaafer studied VEGF in CLL.(10,11)
But
most
of
these
studies
used
microvessel density as a marker of
angiogenesis,
with
manual
count,
restricting their result to blood vessel
count. Another study done by Qasim B. et
al pushed the work step forward by using
vessels , this make assessment more
subjective and computer based.(12)
This work tried to assess angiogenic
markers in NHL, by studying VEGF
expression and its autocrine effect via its
receptor VEGFR expression and the
paracrine
effect
via
CD34+
vessel
expression, using Digimizer software to
analyze
their
immunohistochemical
expression, instead of manual count for
blood vessels and manual score for
VEGF/VEGFR expression.
Many researcher suggest that VEGF may
play dual roles in
tumor angiogenesis,
first through signaling to endothelial cells
27
promoting them to form new blood vessels
paracrine role of VEGF elaborated by
resulting in angiogenesis and second via
lymphoma cells in tumor angiogenesis.(3)
signaling
to
tumor
cells
as
an
(2)
This
autocrine/paracrine growth factor.
Conclusion
research assessed the interaction among
Autocrine and paracrine effect of VEGF is
vascularity
local
evident in NHL, as there is positive
expression of VEGF and VEGFR in NHL
correlation between VEGF expression and
cases.
VEGFR expression, furthermore as tumor
(CD34+
area)
and
vascularity increases expressed by CD34
VEGF expression had positive correlation
with VEGFR expression in different
stained area with the increase in VEGF
expression.
digimizer softwear parameters (intensity
"I", area "A", digital labeling index
"DLI"). This may be due to autocrine
effect of VEGF. Both VEGF and VEGFR
had positive correlation with lymphoma
vascularity expressed by CD34 area "A",
also reinforcing the concept of paracrine
effect of VEGF. These findings are similar
to findings of previous work.(10,13-18)
The
VEGF
reflective
of
immunohistochemistry
effective
local
is
VEGF
signaling. It is expected that MVD
increases with VEGF expression. Average
lymphoma vascularity labeled by CD34+
endothelial cells did
increase with
strength of VEGF staining with statistical
significant in the present work, and this
was also demonstrated in the study by
Berthold et al .
(19)
Dita et al have shown
that higher MVD is present in DLCL
specimens expressing higher levels of
VEGF.(16) This finding is consistent with a
28
References:
1. Ruan, J., et al., Angiogenesis and
6. Nabeel, W.R.,Sahira A.A., and Usama
antiangiogenic therapy in non-Hodgkin's
T.A. Usama, neuvasculrization in prostatic
lymphoma. Ann Oncol, 2009. 20(3): p.
adenocarcinoma as determined by CD34: a
413-24.
retrospective
2. Gratzinger, D., et al., Microvessel
study.
Iraqi
journal
of
medical sciences 2011. 9(4): p. 371-375.
Density and Expression of Vascular
7. Al-Mudallal, S.S., Assessment of bone
Endothelial
Its
marrow angiogenesis using F VIII-related
B-Cell
antigen and its relationship to proliferating
American
cell nuclear antigen (PCNA) in multiple
Journal of Pathology, 2007. 170(4): p.
myeloma. Journal of the Faculty of
1362-1369.
Medicine 2011. 53(2): p. 180-185.
Receptors
Lymphoma
3.
Growth
in
Factor
Diffuse
Large
Subtypes.
Alshenawy,
and
The
H.A.,
Prognostic
8. Mazin, J.I., NabeelA.Rasheed, and A.H.
significance of vascular endothelial growth
Manal, Microvessel density in Renal Cell
factor, basic fibroblastic growth factor, and
Carcinoma. Journal of the Faculty of
microvessel density and their relation to
Medicine 2010. 52(4): p. 424-425.
cell proliferation in B-cell non-Hodgkin's
lymphoma.
Annals
of
Diagnostic
Pathology, 2010. 14(5): p. 321-327.
9. Al-kaptan A.H,I., Uses of CD31
monoclonal Antibody for the Assessment
Of Angiogenesis as a prognostic Factor in
4. Ghaznavi, F., et al., Digital Imaging in
Gastric Adenocarcinoma. Journal of the
Pathology:
Faculty of Medicine 2005. 47(1): p. 42-49.
Whole-Slide
Imaging
and
Beyond. Annual Review of Pathology:
Mechanisms of Disease, 2012. 8(1): p.
121116135809005.
10.
Kareem,
G.M.,
A
Study
of
Angiogenesis Measured by Expression of
CD34
antigen
in
Non-Hodgkin's
5. Al-Sinjery, G.M., Immunohistochemical
Lymphoma, in A thesis submitted to the
Expression of Epstein Barr virus Antigen
council of the College of Medicine at Al-
Latent Membrane Protein-1 and Bcl-2 in
Nahrain University. 2006, AL-Nahrain:
Classical
pathology
Hodgkin’s
and
Lymphoma,
forensic
in
medicine
department. 2011, AL -Nahrain: Baghdad.
baghdad.
11. Ja’afar A.M., In Situ Hybridization
Analysis of p-53 and Bcl-2 Oncogenes and
Angiogenesis Factors VEGF and MMP-9
29
in Chronic Lymphocytic Leukemia, in A
cell lymphoma treated with anthracycline-
Thesis Submitted to College of Medicine
based chemotherapy. Lab Invest, 2007.
and Committee of Graduate Studies
88(1): p. 38-47.
University of Baghdad. 2008, Baghdad.
12.
Qasim,
16. Dita G, et al., Microvessel density and
B.J.,
Assessment
of
expression of vascular endothelial growth
Immunohistochemical
Expression
of
factor and its receptors in diffuse large B-
Matrix
cell lymphoma subtypes. Am J Pathol,
Molecular
Markers:
Metalloproteinase -7 (MMP-7), CD34,
p53, bcl2, Proliferating Cell Nuclear
Antigen
(PCNA),
Estrogen
Progesterone
Receptors
in
Colorectal
Carcinogenesis
and
Human
Using
2007. 170: p. 1362-9.
17. Tzankov, A., et al., Angiogenesis in
nodal
B
cell
lymphomas:
a
high
throughput study. Journal of Clinical
Pathology, 2006. 60(5): p. 476-482.
Specialized Automated Cellular Image
Analysis System. , in A thesis submitted to
18. Zhang, W., et al., Expression of tumor-
the Council of college of Medicine/ Al-
associated
Nahrain University in partial fulfillment of
endothelial growth factor correlates with
the requirements for the degree of Doctor
poor
of Philosophy in pathology. 2011, Al-
lymphoma,
Nahrain: Baghdad.
Leukemia & Lymphoma, 2011. 52(1): p.
macrophages
prognosis
of
not
and
vascular
peripheral
otherwise
T-cell
specified.
46-52.
13. Wang, E.S., et al., Targeting autocrine
and paracrine VEGF receptor pathways
19. Streubel, B., et al., Lymphoma-specific
inhibits human lymphoma xenografts in
genetic
vivo. Blood, 2004. 104(9): p. 2893-2902.
endothelial cells in B-cell lymphomas. N
14. Lee, Y.K., et al., VEGF receptor
aberrations
in
microvascular
Engl J Med, 2004. 351(3): p. 250-9.
phosphorylation status and apoptosis is
modulated by a green tea component,
Correspondence to
epigallocatechin-3-gallate (EGCG), in B-
Dr. Bassam Mohammad Hameed
cell chronic lymphocytic leukemia. Blood,
2004. 104(3): p. 788-94.
Department of pathology and forensic
medicine /collage of medicine /ALNahrain university
15. Gratzinger, D., et al., Prognostic
Email:
significance of VEGF, VEGF receptors,
[email protected]
and microvessel density in diffuse large B
Mobile: 07700664914
30
‫‪Bassam M.Hameed, Hind Sh. Aboob, Raad J.‬‬
‫‪Immunohistochemical expression of VEGF‬‬
‫‪Musa‬‬
‫التقين الوناعي النسيجي للوعاهل ( ‪ (VEGF‬وارتباطه ب ( ‪VEGFR‬و‪ ( CD34‬في االورام‬
‫اللوفاوية عذا هوجكن باستخذام نظام رقوي لتحليل الصور‬
‫م‪.‬د‪.‬بسام دمحم حويذ ‪ ,1‬م‪.‬د‪.‬هنذ شاكر عبعوب ‪ , 2‬ا‪.‬د‪.‬رعذ جابر هوسى ‪3‬‬
‫‪ 1‬يذسط فً فشع ػهى االيشاع وانطة انؼذنً\كهٍح انطة\ جايؼح انُهشٌٍ‬
‫‪ 2‬يذسط فً فشع ػهى االيشاع وانطة انؼذنً\كهٍح انطة\ جايؼح انُهشٌٍ‬
‫‪ 3‬اسرار فً فشع ػهى االيشاع وانطة انؼذنً\كهٍح انطة\جايؼح انُهشٌٍ‬
‫الولخص‬
‫الخلفية ‪ :‬اٌ ًَى األوساو انهًفاوٌح وانرقذو تركىٌُها ًٌكٍ اٌ ٌرى يٍ قثم اثٍٍُ ػهى األقم يٍ اَنٍاخ‬
‫انًشضٍح‪ :‬انرحفٍض ‪ autocrine‬انخالٌا انسشطاٍَح ػٍ طشٌق انرؼثٍش األوػٍح انذيىٌح غشائً ػايم‬
‫انًُى (‪ )VEGF‬واألوػٍح انذيىٌح غشائً ػايم ًَى يسرقثالخ (‪ )VEGFR‬يٍ قثم خالٌا سشطاٌ‬
‫انغذد انهًٍفاوٌح‪ ،‬وانرأثٍشاخ َظٍش انظًاوي يٍ انًكشوٌح انىسو ‪ proangiogenic‬ػهى األوػٍح‬
‫انًحهً‪.‬‬
‫انسشطاٍَح‬
‫انذيىٌح‬
‫األهذاف‪ :‬ذقٍٍى ذأثٍش ‪ autocrine‬يٍ ‪ ،VEGF‬يٍ خالل دساسح ػالقح انرؼثٍش ‪ VEGF‬يغ‬
‫يسرقثالخ انرؼثٍش ‪ VEGFR‬فً ‪ .NHL‬ونرقٍٍى ذأثٍش َظٍش انظًاوي يٍ ػايم ًَى تطاَح االوػٍح‪،‬‬
‫يٍ خالل دساسح ػالقح انرؼثٍش ‪ VEGF‬يغ ‪ CD34‬أػشب ػٍ انخالٌا انثطاٍَح فً سشطاٌ انغذد‬
‫(‪.)NHL‬‬
‫هىدجكٍٍ‬
‫غٍش‬
‫انهًٍفاوٌح‬
‫الوواد والطرق‪ :‬ذى ذظًٍى دساسح يقطؼٍح‪ .‬أدسجد يا يجًىػه ‪ 66‬يٍ ػٍُاخ األَسجح نُخاع انؼظى‬
‫فً انذساسح‪َ ،‬ى ال ذشخٍض ل ‪ NHL‬وفقا ‪ .working formulation‬يٍ كم ػٍُح أخزخ ‪3‬‬
‫أقساو‪ ،‬وطثغد ‪ immunohistochemically‬ل‪ ،CD-34‬ػايم ًَى تطاَح االوػٍح و‪.VEGFR‬‬
‫انخهىٌح‬
‫طىسج‬
‫وذحهٍم‬
‫َظاو يرخظض انً‬
‫تاسرخذاو‬
‫انرشقٍى‬
‫ذى ذُفٍز‬
‫‪.3.7.3‬‬
‫اإلطذاس‬
‫‪،Digimizer‬‬
‫تثشَايج‬
‫النتائج ‪:‬اسذثظ ‪ VEGF‬انًُاػى انًؼهًاخ انشقًٍح اسًه يؤشش انؼالياخ انشقًٍح (‪ )DLI‬إنى حذ‬
‫كثٍش يغ يا ٌهً‪ ،VEGFR (DLI) [P = 0.042 :،‬ص = ‪ CD34 ،]3.324‬يُطقح انًهىٌ ( )‪A‬‬
‫‪ ،[P = 0.037‬ص = ‪ .]3.556‬أٌضا ‪ )VEGFR (DLI‬اسذثظ تشكم يهحىظ يغ ‪.)CD34 (A‬‬
‫الخالصة‪ :‬ذأثٍش ‪ Autocrine‬وَظٍش انظًاوي يٍ ػايم ًَى تطاَح االوػٍح هى واضح فً ‪،NHL‬‬
‫كًا أٌ هُاك ػالقح إٌجاتٍح تٍٍ انرؼثٍش ‪ VEGF‬وانرؼثٍش ‪ ،VEGFR‬وكًا صٌادج األوػٍح انذيىٌح‬
‫‪.VEGF‬‬
‫انرؼثٍش‬
‫فً‬
‫صٌادج‬
‫يغ‬
‫ٌرُاسة‬
‫نهىسو‬
‫ألكلوات الوفتاحية‪VEGFR ،VEGF ،NHL :‬‬
‫‪31‬‬
Original article
Evaluation of the changes in iron homeostasis and hepcidin concentration in
preeclamptic patients
Noora Abd Ali Muhsin1, Subuh Salim Al-Mudalal2, Bassam Mohammad Hameed3
1 M.B.CH.B /AL-Imamin AL-Kadhmin medical city
2 Professor of Haematopathology/ M.B.Ch.B /M.Sc /F.I.C.M.S. (Pathology/Haematology)/ Department of
3 Msc. Pathology (haematology), Ph.D. Pathology (haematology) Lecturer Department of pathology and forensic
medicine /collage of medicine /AL-Nahrain university
Received 31/12/2015
accepted 15/2/2016
Abstract
Background: Plasma iron is increased in preeclampsia (PE) in comparison to normal pregnant women.
The relation between iron homeostasis and inflammation is hepcidin. Hepcidin is an acute phase reactant
protein which has major role in iron hemostasis.
Objectives: To evaluate serum iron, total iron binding capacity (TIBC), serum ferritin and serum
hepcidin levels in preeclamptic pregnant women in relation to non preeclamptic pregnant women, who
were not on any iron supplement regimen.
Materials and Methods: This case control study was conducted on twenty pregnant women in the third
trimester of pregnancy suffering from preeclampsia that had not received iron supplement or had blood
transfusion within last three months, those patients attended the obstetrics and gynecology department at
(AL-Imamin AL-Kadhmin medical city) between May to August 2013. Along with those patient twenty
non preeclamptic pregnant women who were age and gestational age matched were included as control
group. Moreover any subject presented with active infection, chronic diseases, chronic blood loss or twin
pregnancy was excluded. A total of 5 ml of venous blood sample was obtained from each patient and
control and tested for measurement of Hb, PCV, and MCHC by automated device whereas, serum of iron
and TIBC, ferritin and hepcidin were measured by ELISA technique.
Results: The mean level of Hb, PCV, MCHC, serum iron, serum ferritin and serum hepcidin in
preeclamptic patients were higher than those of control group (P value of < 0.05).There was a nonsignificant correlation between serum iron and hepcidin in preeclamptic patients (r=0.234, P= 0.32)
whereas there was a significant strongly positive correlation between serum iron and hepcidin in the
control group (r=0.839, P = 0.003).
Conclusions: In preeclamptic patients serum iron concentration is increased in spite of high hepcidin
concentration which might indicate a resistance to the iron-decreasing action of hepcidin.
Keywords: preeclampsia, hepcidin; pregnancy; iron regulation
32
Evaluation of the changes in iron homeostasis
Noora A.A.M, Subuh S. Al-Mudalal, Bassam M.H.
Introduction
Preeclampsia,
a
systemic
syndrome
The aims of the study were to evaluate
manifested primarily by hypertension and
serum iron, total iron binding capacity
proteinuria, presents mainly in the second
(TIBC), serum ferritin and serum hepcidin
half of pregnancy, and affects approximately
levels in pregnant women suffering from
3% to 5% of pregnancies worldwide. (1)
preeclampsia and to compare them with non
Normal women has a decrease in serum iron
and ferritin during the third trimester of
pregnancy as their stores of iron are depleted
because
of
fetoplacental
demand
and
required expansion of red cell mass. (2,3)
preeclamptic pregnant women.
This study was conducted on twenty
preeclamptic pregnant women in the third
trimester of pregnancy who were attending
Plasma iron concentrations and ferritin are
the obstetrics and gynecology department at
increased,
whereas
total
(AL-Imamin AL-Kadhmin medical city)
capacity
(TIBC)
is
iron
binding
in
between May to August 2013. Along with
preeclampsia. The increase in plasma iron is
twenty non preeclamptic pregnant women
in contrast to inflammation characteristic for
served as control and who were age and
preeclampsia.
iron
gestational age matched and both groups had
(4)
a parity of three or less and twin pregnancy
Hepcidin, a negative regulator of iron
were excluded. All of the preeclamptic
The
link
decreased
between
homeostasis and inflammation is hepcidin.
absorption and Recycling
(5)
, is a small
patients were diagnosed previously by
peptide produced by the hepatocytes in
obstetrical specialist and the mean arterial
response to increased body iron and
pressure (MAP) was measured for all
inflammation.(6) The increase in plasma iron
pregnant women.
concentrations
despite
concentrations
in
high
preeclampsia
hepcidin
might
MAP
=
[(2×diastolic
blood
pressure)+systolic blood pressure] / 3.
indicate a resistance to the iron-decreasing
action of hepcidin. (4,7)
A written consent for participation in the
study was obtained from each subject
included in the study.
33
Moreover pregnant women included in the
ARCHITECT, Abbott,USA). The TIBC was
study were not receiving iron supplement
calculated from serum iron concentration
and had not received blood transfusion
plus unsaturated iron binding capacity
within the last three month. Also both
(UIBC).Ferritin was calculated by enzyme
groups should not suffer from active
immunoassay based on standard method
infection, any chronic disease, and chronic
using
blood loss.
(Minividas,
automated
immunoanalyzer
Biomerieux,
France)
and
commercially available kit (VIDAS Ferritin,
Blood sampling:
30 411, Biomerieux, France). Hepcidin was
A total of 5 ml of venous blood sample was
calculated in patient and control serum by
obtained from each patient and control by
Enzyme
venipuncture from the cubital fossa under
(ELISA) based on biotin double antibody
aseptic technique. The blood sample was
sandwich technology using standard enzyme
divided into two smaller samples as follows:
reader
1-First sample comprised of two milliliters
of blood in Ethylene diamine tetra acetic
acid (EDTA) tube for measurement of Hb,
linked
(ELISA
immunosorbent
Reader,
assay
Diagnostic
automation inc, USA) and a commercially
available kit (Human Hepcidin ELISA kit,
MBS164980, MyBioSource, USA).
PCV, MCHC by automated haematology
Computerized
analyzer (Sysmex KX-21N, Japan).
performed using SPSS (statistical package
2-Second
sample
comprises
of
three
milliliters of blood in plain tube to obtain
serum by centrifugation of clotted blood for
measurement of iron and UIBC, ferritin and
hepcidin. Serum Iron and UIBC was
estimated by the direct colorimetric assay
using automated analyzer (ARCHITECT
of
social
statistical
sciences),
analysis
version
16
data were expressed as mean±SD. Student ttest was used to estimate the difference
between two means. Correlation test was
used to find the association between two
numerical variables.
available kit using for (IRON, 6K95-30 and
6K95-41, ARCHITECT, Abbott, USA), and
UIBC
(UIBC
LIQUID,
4P79-30,
with
Microsoft office excel 2007.The numeric
c4000, Abbott, USA) and by commercially
for
were
34
Results
This study included twenty preeclamptic
control group. Only the mean level of TIBC
pregnant women in third trimester of
was lower in preeclamptic patients than
pregnancy with mean age was 28.5±4.9
control group.
years. Along with twenty non preeclamptic
pregnant
women who
were
age
and
gestational age matched and who served as
control group, whose
mean age was
28.3±6.3years. The mean arterial pressure was
significantly higher in preeclamptic patient
(114.9±8.9 mmHg ) than the mean arterial
pressure
control
group
(87.8±6.2
Furthermore , there was a non significant
correlation between serum iron and hepcidin
in preeclamptic patients (r=0.234, P= 0.32)
whereas
this
correlation
was
strongly
positive in normal pregnant control group
(r=0.839, P = 0.003). (Figure 1)
mmHg)
Haematological and biochemical parameters
of preeclamptic patients and control group
were presented in Table 1, showing that the
mean level of Hb,PCV,MCHC as well as
mean level of serum iron, serum ferritin,
serum hepcidin of preeclamptic patients
were significantly higher than those of
35
Table 1: Haematological and biochemical parameters of preeclamptic patients and control group
*Significant P value(<0.05)
36
Figure 1. Correlation between serum iron and hepcidin in control group (P = 0.003)
37
Discussion
The present study had revealed that iron
profile (includes S.iron, TIBC, S.ferritin was
within normal range in preeclamptic patient
although they were not receiving any iron
supplement.
Whereas the iron profile in
normal pregnancy women was that of iron
deficiency anemia, which was expected
since
they
were
supplements.
Those
not
receiving
results
iron
were
in
agreement with studies done by Tasneem
zafar et al
(3)
, Gergely Toldi et al
(4)
and
Margaret P. Rayman et al(8). These results
may be attributed to that, in preeclampsia
there is impairment of trophoblast invasion
to the maternal spiral arteries resulting in
necrotic and hemorrhagic areas in the
placental tissue. The injured red blood cells
in those area will be a source of free iron
radical. (8,9)
Additionally, Margaret P. Rayman et al in
their study had found that, iron released
from
red-cell
destruction of damaged
placenta are clearly capable of initiating and
propagating lipid peroxidation, results in
endothelial-cell damage in preeclamptic
patients.(8)
So
we
may
propose
that
disturbance of iron status is a cause and
result
for
preeclamptic
changes.
Consequently, preeclamptic patients had
normal Hb, PCV and MCHC levels, whereas
control group had low Hb, PCV and MCHC
levels since those patients had not received
iron supplement. Those results were in
agreement with studies done by Tasneem
zafar et al.(3,10)
This study showed that, the mean level of
serum hepcidin in preeclamptic patients was
within normal range and significantly higher
than that control group and there was no
correlation of its level with S. iron. This
result was in agreement with study done by
Gergely Toldi et al, who found that
increased in the pro-inflammatory cytokine;
interleukin-6 (IL-6) in preeclamptic patients
as a result of inflammatory reaction, results
in high hepcidin concentration in those
patients.(4) despite of high S. iron level
which might indicate a resistance to the
iron-decreasing action of hepcidin. This
resistance to hepcidin may be due to
functional or structural abnormalities of
ferroportin. It is well known that normally
the chronic inflammation decreases iron
availability through decreasing the release of
iron from the macrophages to the plasma as
a result of raised serum hepcidin (11), but this
drive is absent in preeclamptic patients.(4,7)
Thus we may propose that in preeclamptic
patients the ongoing inflammation had no
38
effect on iron status through hepcidin. (7,12)
Where as in normal pregnant women
hepcidin level was significantly decrease in
relation to low S. iron level .
Conclusion
In
preeclamptic
patients
serum
iron
concentration is increased despite of high
hepcidin concentration thus we may suggest
that pregnant women not receiving iron
therapy and even more had normal Hb , high
S.iron ,and high hepcidin may suggest an
impeding preeclampsia , close follow up is
recommended , thus for these pregnant
women iron status should be assessed before
giving iron supplement.
39
Reference:
1. Maynard, S.E. and S.A. Karumanchi,
8. Rayman, M.P., et al., Abnormal iron
Angiogenic factors and preeclampsia. Semin
parameters in the pregnancy syndrome
Nephrol, 2011. 31(1): p. 33-46.
preeclampsia. Am J Obstet Gynecol, 2002.
2. Malek-mellouli, M., et al., [Iron status in
187(2): p. 412-8.
pregnant women and its changes during
9. Valenzuela, F.J., et al., Pathogenesis of
preeclampsia]. Tunis Med, 2013. 91(10): p.
preeclampsia: the genetic component. J
577-82.
Pregnancy, 2012. 2012: p. 632732.
3. Zafar, T. and Z. Iqbal., Iron status in
10. Koenig, M.D., et al., Hepcidin and iron
preeclampsia. Professional Medical Journal,
homeostasis during pregnancy. Nutrients,
2008. 15(1): p. 74-80.
2014. 6(8): p. 3062-83.
4. Toldi, G., et al., Hepcidin concentrations
11. Choudhry, V.P., Hepicidin and its role in
and iron homeostasis in preeclampsia. Clin
iron metabolism. Indian J Pediatr, 2010.
Chem Lab Med, 2010. 48(10): p. 1423-6.
77(7): p. 787-8.
5. Collins, J.F., M. Wessling-Resnick, and
12.
M.D. Knutson, Hepcidin regulation of iron
iron status in pre eclampsia. Mymensingh
transport. J Nutr, 2008. 138(11): p. 2284-8.
Med J, 2006. 15(1): p. 22-4.
6.
Camaschella,
C.
and
L.
Silvestri,
Molecular mechanisms regulating hepcidin
revealed
by
hepcidin
Basher, K. and K. Deb, Alteration in
disorders.
ScientificWorldJournal, 2011. 11: p. 135766.
7. Kandi, S., et al., Pre Eclampsia and Iron
Status: A Review. American Journal of
Correspondence to
Dr. Bassam Mohammad Hameed
Department of pathology and forensic
medicine /collage of medicine /AL-Nahrain
university
Email:
[email protected]
Medical and Biological Research, 2014.
2(6): p. 121-123.
Mobile: 07700664914
40
‫‪Noora A.A.M, Subuh S. Al-Mudalal,‬‬
‫‪Evaluation of the changes in iron homeostasis‬‬
‫‪Bassam M.H.‬‬
‫تقييم التغيرات في تركيز الهبسيدين وتوازن الحديد عند الحوامل المصابات بتسمم الحمل‬
‫د‪.‬نورا عبد علي محسن‬
‫‪M.B.Ch.B‬‬
‫ا‪.‬د‪.‬صبح سالم عبد اللطيف المدلل‬
‫م‪.‬د‪.‬بسام محمد حميد‬
‫)‪M.B.Ch.B/M.Sc/F.I.C.M.S.(Haematology‬‬
‫)‪Msc. Pathology (haematology), Ph.D. Pathology (haematology‬‬
‫الملخص‬
‫الخلفية‪ :.‬يتم زيادة بالزما الحديد في تسمم الحمل بالمقارنة مع النساء الحوامل الطبيعيين و العالقة بين توازن الحديد‬
‫وااللتهاب هي هيبسيدين‪ .‬هيبسيدين هو بروتين تفاعلي حاد المرحلة الذي له دور كبير في توازن الحديد‪.‬‬
‫األهداف‪ :‬تقييم مستويات حديد المصل‪ ،‬ومجموع الحديد ملزم قدرة ‪ ،‬مصل الفيريتين وهيبسيدين المصل في النساء‬
‫الحوامل المصابات بنسمم الحمل فيما يتعلق بالنساء الحوامل االصحاء‪ ،‬الذين لم يكونوا على أي نظام عالجي للحديد‪.‬‬
‫المواد والطرق‪ :‬أجريت هذه الدراسة على عشرين من النساء الحوامل في الثلث الثالث من الحمل اللواتي يعانين من‬
‫تسمم الحمل و لم يعطين الحديد و لم يتم نقل الدم لهم في األشهر الثالثة األخيرة‪ ،‬هوالء الحوامل حضرن الى قسم‬
‫أمراض النساء والتوليد في مستشفى االمامين الكاظمين بين مايو‪-‬أغسطس عام ‪ .3102‬وإلى جانب هؤالء المرضى‬
‫عشرين امرأة حامل غيرمصابات بتسمم الحمل الذين كانوا في نفس العمر والعمر الحملي وأدرجت كمجموعة مراقبة‬
‫مطابقة‪ .‬وعالوة على ذلك تم استبعاد أي حامل مع عدوى نشطة‪ ،‬او لديها أمراض مزمنة‪ ،‬اوفقدان الدم المزمن أو‬
‫الحمل التوأم‪ .‬تم الحصول على ما مجموعه ‪ 5‬مل من عينة من الدم الوريدي من كل مريض ومراقبة واختبار لقياس‬
‫الهيموغلوبين‪ ،PCV ،‬و‪ MCHC‬بواسطة جهاز آلي في حين تم قياس مصل الحديد ‪ ،TIBC‬الفيريتين وهيبسيدين‬
‫‪.ELISA‬‬
‫تقنية‬
‫بواسطة‬
‫النتائج‪ :‬كان متوسط مستوى الهيموجلوبين‪ ،MCHC ،PCV ،‬حديد المصل‪ ،‬الفيريتين في المصل وهيبسيدين‬
‫المصل في المرضى الذين يعانون تسمم الحمل أعلى من تلك التي المجموعة الضابطة (قيمة ‪ P‬من <‪ )1.15‬كان‪.‬‬
‫هناك عالقة غير ذات داللة إحصائية بين الحديد في الدم وهيبسيدين في المرضى الذين يعانون تسمم الحمل (‪= r‬‬
‫‪ ) P = 0.32 ،1.320‬في حين كان هناك ارتباط إيجابي قوي كبير بين الحديد في الدم وهيبسيدين في السيطرة على‬
‫‪.)P‬‬
‫=‬
‫‪0.003‬‬
‫‪،1.820‬‬
‫(‪=r‬‬
‫المجموعة‬
‫االستنتاجات‪ :‬كان الحوامل مع تسمم الحمل لديهم زيادة تركيز الحديد في الدم على الرغم من تركيز هيبسيدين العالية‬
‫هيبسيدين‪.‬‬
‫من‬
‫الحديد‬
‫خفض‬
‫على‬
‫للعمل‬
‫مقاومة‬
‫وجود‬
‫إلى‬
‫تشير‬
‫قد‬
‫التي‬
‫ألكلمات المفتاحية‪ :‬تسمم الحمل‪ ،‬هيبسيدين‪ .‬حمل؛ تنظيم الحديد‬
‫‪41‬‬
Original article
The results analysis of complete blood count during the first half of
2015 at the Central Child Teaching Hospital in Baghdad.
Rasha Tariq Jawad1 , Ebtehal Ali Hussien2
1
MD. M.B.Ch.B. F.I.C.M.S/Hematopathology ,Senior Specialized Hematopathologist, Manager of the
Hematology Unit, Laboratory Department / Central Child Teaching Hospital ,Baghdad ,Iraq.
2
BMLT, Laboratory technician / Hematology Unit, Laboratory Department / Central Child Teaching
Hospital ,Baghdad ,Iraq.
Received 5/1/2016
accepted 15/2/2016
Abstract:
Background: Complete blood count (CBC) is the most commonly requested test by
physicians. The central child teaching hospital is the second largest pediatric hospital in
IRAQ. We review the CBC for the first half of 2015 at that hospital.
Objectives: this study was arranged to explore the prevalence of anemia, leucocytosis,
leucopenia, thrombocytosis, thrombocytopenia, using automated CBC counter Emerald &
Ruby Abbott for outpatient and inpatients respectively.
Patients and methods: A retrospective study included a total of 19341 patient attended
central child teaching hospital (from the 1st of January -1st of July 2015). All of them did
complete blood picture test using ruby Abbott and emerald Abbott hematology autoanalyzer,
14418 of them were inpatients and 4723 patients attended to the outpatient clinic.
Results: the results were analyzed as anemia, leucocytosis, leucopenia, thrombocytosis,
thrombocytopenia for the whole patients and for each month to the inpatients so that to
analyze the result according to season. Anemia was seen more commonly in the inpatients
(30.79%) than the outpatient (20.8%). Leucopenia was seen more in outpatients (17.15%)
than in inpatients (8.1%), while leukocytosis shown to be (10.8%) of inpatients and 2% of
outpatients. Thrombocytopenia was (8.3%) of inpatient and (3.1%) of outpatients. Regarding
the monthly incidence we found that the highest percentage of anemia in outpatients seen at
May (42%), while the lowest was seen at January (19.76%).Leucocytosis and thrombocytosis
both showed the highest percentage at January (19.76%), (15.29%) respectively.
Conclusion: anemia, leucocytosis, and thrombocytosis seen in inpatients more than
outpatients ,leucopenia seen in outpatients more than inpatients ,thrombocytosis showed near
results for in and out patients but a little higher for inpatients.
Keywords: analysis, CBC, children
42
The results analysis of complete blood count
.Rasha Tariq Jawad , Ebtehal Ali Hussien
Introduction:
Complete blood picture is the most
commonly requested test by physician
as it is easy and highly informative for
patient’s health. It requires minimum
amount of anti-coagulated whole blood
and done on automated blood count
machine lasting few minutes to get the
results.
more global failure of hematopoiesis,
caused by conditions such as aplastic
anemia,
whether the patient have anemia,
anemia,
myelofibrosis, or leukemia, or may
suggest a rapid destruction or trapping
of
all
blood
elements,
such
as
hypersplenism, localized coagulopathy
in
The primary field of interest is
Fanconi
a
large
hemophagocytic
(HLH)
or
hemangioma
or
lymphohistiocytosis
macrophage
(2)
activation
whether the WBC count have evidence
syndrome (MAS)
. The WHO show
of infection and whether the platelets
that the prevalence of anemia is
hemostasis.(1)Pediatric
(47.4%)
anemia refers to a hemoglobin or
children
hematocrit level lower than the age-
Iraq in children under 5 from 1995-
adjusted reference range for healthy
2011 is 36%
children. Physiologically, anemia is a
of anemia seen more than general
condition in which reduced hematocrit
population ,a study in India show that
or
anemia in inpatient in one tertiary
count
affect
hemoglobin
levels
lead
to
among
(3)
preschool
aged
prevalence of anemia in
(4)
. Inpatients prevalence
hospital was( 72.79%)(5) ,
diminished oxygen-carrying capacity
pediatric
that does not optimally meet the
another study in Brazil showed the
metabolic demands of the
body.
prevalence of anemia in pediatric
Anemia is not a specific disease entity
hospital to be (56.6% ) 10(6).while it is
but is a condition caused by various
59%,and 24% respectively in the
underlying pathologic processes. (2) In
general population of these countries(4).
addition, conditions are emphasized in
Leukocytosis is a common laboratory
which anemia is the only hematologic
finding
abnormality.
of
practice, in the emergency department
anemia with leucopenia, neutropenia,
or a medical or surgical setting.
or thrombocytopenia may suggest a
Generally, the vast majority of cases of
The
combination
encountered
in
hospital
43
leukocytosis are reactive and benign—
is
resulting from liberation of various
problem in routine practice than is
cytokines
the
leukocytosis. n general, leukopenia
development of leukocyte precursors
may result from decreased marrow
and release of mature cells from the
production of leukocytes precursors,
marrow, endothelium,
by
that
stimulate
and spleen.
a
less
commonly encountered
peripheral
destruction
or
Most reactive episodes of leukocytosis
sequestration of circulating leukocytes,
are
or by autoimmune cellular damage or
neutrophilic
in
nature
(“neutrophilia”) and result from a
myriad of stressors.
(7)
destruction.
The
most
common
Occasionally,
etiology of leucopenia is decreased
the total leukocyte count will exceed
marrow production due to a variety of
25,000 cells/mm3, with the majority of
disorders that damage the developing
cells
leukocyte mass in the bone marrow (7).
being
polymorphonuclear
leukocytes. This scenario is referred to
as a leukemoid reaction, and may be
difficult
to
differentiate
from
a
A low
platelet
(thrombocytopenia)
may
count
also
be
leukemic picture, hence the name
detected in the complete blood count.
“leukemoid.” As such, in patients with
Thrombocytopenia which is defined as
leukemoid
platelet less than 150× 103 per µL. It is
reactions,
the
main
differential diagnostic concerns include
often
chronic myelogenous leukemia, acute
complete blood picture test
myelogenous
other
with platelet count greater than 50×103
myeloproliferative disorders. A typical
per µL rarely have symptoms. Platelet
leukemoid reaction, however, occurs in
count from 30 to 50 × 103 per µL
the presence of an acutely stressful or
rarely manifest as purpura. A count
inflammatory/infectious event, such as
from 10 to 30× 103 per µL may cause
hemorrhage,
febrile
bleeding with minimal trauma .a
episodes, sepsis, trauma, pancreatitis,
platelets count less than 5×103 per µL
or
difficile
may cause spontaneous bleeding This
infection. Clostridium difficile has the
may be due to bone marrow problems,
unique
some medications or , immunologic or
leukemia,
or
hemolysis,
Clostridium
propensity
of
causing
discovered
on
patient
leukemoid reactions in cases of severe
genetic
colitis,
from
disease, or cancers such as leukemia(8)
. Leukopenia
thrombocytosis is often associated with
and
likely
liberation of cytotoxins
results
(7)
problems,
incidentally
advanced liver
44
What Affects the Test (9)
infection or an inflammation such as
osteomyelitis or rheumatoid arthritis
,hematological causes include chronic
blood
loss
red
cell

occurs as consequence of WBC
destruction
agglutination
,splenectomy and rebound following
recovery
from
suppression.
bone
marrow
Moderately
increased
platelet count does not usually have
Factitiously low WBC occasionally
storage
,prolonged
sample
,abnormally
fragile
cells(leukemia)

A very high WBC count is more
common and usually result from
pathological implication (9).
failure of RBC lysis .this occurs
The complete blood count values are
with RBC of neonates or uremia or
usually reported based on the number
the
of cells in a specific volume of blood.
hemoglobin such as S or C Hb.
Fully
automated
multichannel

presence
of
abnormal
Low platelets count may be due to
instrument usually measure from 8 to
giant platelets. Identified as red cells
20 component .automated instruments
or
have high level of precision ,if
Clumping
instrument are carefully calibrated and

of
EDTA-induced
platelets.
High platelet count may be due to
their correct operation is ensured by
marked microcytosis or fragmented
quality control procedure they produce
red cells or fragmented WBC or due
test that are generally accurate
(9)
.A
complete blood count may be done as
to bacteria or fungi.

The automated MCV& Hct are
part of a regular physical examination.
prone
Normal values for the complete blood
resulting from microclots or partial
count (CBC) tests depend on age, sex,
clotting ,extreme microcytosis and
how high above sea level you live, and
the presence of cryoglobulin or cold
the type of blood sample .each ethnic
agglutinins the latter cause factitious
group has its normal range and many
elevation
literatures establish their own normal
agglutinated cells counted as single
range for specific hospitals in these
cell.
towns
(10,11,)
to
certain
of
errors.
MCV
as
those
the
. Table (1) shows the
normal value of infant and children
Patients and Methods:
which clarify the difference with age.
A total of 19141 patients attended and
did complete blood count (CBC) at the
45
Central Child Teaching Hospital in
light or change the potential between
Baghdad Iraq for the period from the
tow electrodes (depending on the
1st of January to the 1st of July 2015.
technology used) which last as long as
We retrospectively analyzed CBC
the cell take to pass ,the number of
results of those patients. 14418 was
pulses indicate the count ,the height of
hospitalized (inpatients), 4723 was
the pulse indicate the volume of the
outpatients. 2 ml of venous blood was
cell passing through (MCV) .WBC is
collected in k3 EDTA tubes from the
determined in whole blood in which
patients, and the CBC for inpatients
red cells have been lysed .Platelets are
made on Rupy Abbott autoanalyzer
counted in whole blood using the same
working on principle of electrical
technique with an upper threshold is
impedance. the outpatient CBC done
needed to separate platelets from red
on Emerald Abbott Autoanalyzer. The
cells and a lower threshold to separate
test done at the hematological units of
plate lets from debris and electronic
the outpatients laboratory and the
noise. Three part differential count
central laboratory. the result was
assigns cells to categories usually
compared
designated: granulocytes (large cells),
with
hematological
the
normal
schedule
of
values
for
lymphocytes
(small
cells),
and
normal infants and normal children
monocytes (mononuclear or middle
that is published on Dacie and Lewis
cells .three part differential counts
practical hematology eleventh edition
from a single channel instrument (1,9,12)
(9)
The results of the first half of 2015
is analyzed according to the incidence
of anemia ,leucocytosis , leucopenia,
thrombocytosis , thrombocytopenia.
The automated counters measure the
hemoglobin
concentration
by
modification of the manual HiCN
method with cyanide reagent ,RBC and
other blood cells counted by aperture
impedance , blood is highly diluted in
a buffered electrolyte solution under
controlled condition the diluted blood
The normal values may differ slightly
based on the reference range and the
machine used in the laboratory and,
therefore, the results may be slightly
different from one laboratory to the
next
(10,11)
. The normal reference range
is typically provided and printed with
the results of the complete blood count
for accurate interpretation. Different
laboratories
may
report
slightly
different reference ranges.(13)
passed through the aperture scattering
46
Table (1); hematological values for normal infants and normal children (Dacie
and Lewis 11th edition) (9)
Parameter
RBC×10
12
/L
birth
5-7
Day
Day
Day
1
2
3-6
1 year
3
7
14
month
month
months
4-6.6
4.9-6.3
3.6-6.2
3-5.4
3.1-
4.1-5.3
4.3
14-22
Hb g/dl
45-75
Pcv(range)
100-120
MCV
15-21
13.5−21.5
45-67
92-118
42-66
88-126
12.5−
11.5-
20.5
16.5
31-71
86-124
31-37
MCH
11.1-14.1
28-42
92-
87-
116
103
6-12
years
years
4-5.2
5.1
9.4-14
33-53
3.9-
2-6
30-36
30-40
30-38
11-
11.5-
14
15.5
34-40
35-45
68-84
72-84
75-78
75-95
24-30
25-29
24-30
25-33
9
120-400
50-350
50-100
20-60
30-50
40-100
30-100
9
WBC×10 /L
10-26
7-23
6-22
5-21
5-15
6-18
6-16
5-15
5-13
N×109
4-14
3-5
3-6
3-9
1-5
1-6
1-7
1.5-8
2-8
L×109/L
3-8
2-8
3-9
3-16
4-10
4-12
3.5−11
6-9
1-5
M×109/L
0.5-2
0.5-1
0.1-1.7
0.3-1
0.4−
0.2-1.2
retics×10 /L
3-7
0.2
-1.0
1.2
E×109/L
0.1-1
0.1-2
0.1−0.8
0.1−0.9
0.2-1
Platelets
100−450
210−500
160−500
170−500
200-
210-
500
650
The reported values are either directly
0.2 -
1.0
200-550
200-
170-
490
410
The calculated values are:
measured or calculated by the machine.

The measured values are:


WBC number

RBC number

Mean
Corpuscular
Hematocrit (HCT)
Mean Corpuscular Hemoglobin
(MCV)

Volume
(MCV)

Hemoglobin (Hg)

Platelet count

Mean platelet volume(MPV)
Concentration (MCHC)

(MCH)

Red
Cell
Distribution
Width
(RDW)
47
Results
A total of 19141 patients included in
Table (3) showed that the highest
this study with age range from (1day-
percentage of anemia was at May
14 years old). About third of the
(42,9%) and the lowest was seen at
inpatients (30.79 %) and only 20.8% of
January
the
low
percentage of leucocytosis was seen at
(table
January (19.76%) for inpatients, the
outpatients
were
with
hemoglobin
concentration
2).leucopenia
seen
in
8.1%
of
(19.76%).
The
highest
lowest percentage seen at June (4.1%).
inpatient and 17.15% of the outpatients
Leucopenia was seen comparable
while leucocytosis seen in 10.8%. of
the whole five months and a lower
the
percentage in June (5.1%) (Table 4).
inpatients
and
2%
of
the
for
outpatients . Thrombocytopenia seen in
Patients with thrombocytosis were
8.3% of the inpatients and 3.11% of
higher in January (15.9%) and the
the outpatients while thrombocytosis
lowest percentage was seen in June
seen in 6.8% of the inpatients and
(2.35%),
5.14% of the out patients (Table 2).
while
thrombocytopenia
showed the highest percentage in April
(12.72%) and the lowest in January
(2.68%) (Table 5).
Table (2): percentage of high Hb, WBC, platelet, and low Hb, WBC, platelet for
inpatient and outpatient.
Test
IP(N=14419)
%
OP(N=4723)
%
Low Hb.
4438
30.79%
984
20.8
Low WBC
1166
8.1%
810
17.15%
High WBC
1562
10.8%
96
2%
Low plt.
1194
8.3%
147
3.11%
High plt.
981
6.8%
243
5.14%
48
Table (3): the percentage of anemic patients in the inpatients for each month and
the total of the 1st half of 2015.
Month
No. of patient
Patients with low Percentage
Hb.
January
2419
478
19.76%
February
2560
873
34.1%
March
2227
767
34.49%
April
2367
569
24.03%
May
2383
1023
42,93%
June
2462
728
29.56%
Total
14418
4438
30,79%
Table (4) the percentage of leucopenia& leucocytosis for each month and the
total of the 1st half of 2015.
Month
No.
of Patients
patients
Patients with
with low Percentage
high
WBC
WBC
Percentage
January
2419
212
8.76%
478
19.76%
February
2560
203
7.92%
218
8.51%
March
2227
183
8.21%
306
13,74%
April
2367
231
9.75%
269
11.36%
May
2383
212
8.9%
191
8.01%
June
2462
125
5.1%
100
4.1%
Total
14418
1166
8.1%
1562
10.8%
49
Table (5): the percentage of thrombocytopenia and thrombocytosis for each
month and the total of the 1st half of 2015.
Month
Pat. No.
Low plt.
Percentage
High plt.
Percentage
January
2419
65
2.68%
370
15.29%
February
2560
137
5.35%
87
3.39%
March
2227
192
8.62%
261
11.71%
April
2367
301
12.72%
78
3.29%
May
2383
249
10.45%
127
5.32%
June
2462
250
10.15%
58
2.35%
Total
14418
1194
8.3%
981
6.8%
Discussion
The result of our study showed that
become anemic at some point during
anemia seen in 30% of the hospitalized
their childhood and adolescence(5) .
patient and 20% of the outpatient was
anemic. prevalence of anemia seen
differ from one country to another 10%
of hospitalized adult patients seen to be
anemic in one study(14) while another
study in Brazil show that 56% of
hospitalized children under the age of
5 are anemic.(6).in a study in India
which chose the same age as ours they
show that anemia seen in 72% of the
hospitalized patients
(5)
. The studies
show that anemia worldwide seen in
43%undre 5 years(14) , even in the
developed world 21-26%
Leucopenia in this study seen in
(8.1% ) of the inpatient and (17.15%)
of the outpatient . as we depend on the
table of Dacie and Lewis for CBC
count
,a WBC
below 5×109 /L
considered leucopenia that why we as
middle eastern people should establish
our own normal range
(10,12)
,even in
the west black people have a lower
normal leukocytes than white and the
books ask the physician not to do
unneeded test for those patients and to
put this in mind (7)
50
Leucocytosis
hospitalized
seen
patient
in
10.8%
of
cause in children the incidence 100
2%
of
cases per million
and
50%
usually hospitalized patients are more
Psuedothrombocytopenia from EDTA
ill than outpatients.
dependent agglutinin should be put in
inpatients and 5.14% of the outpatients
.thrombocytosis in children is common
but usually without symptoms the
cause mostly infection ,trauma, surgery
,renal
disease
and
chronic
inflammation .in a study in Taiwan
thrombocytosis
hospitalized
hospital
result
seen
in
patient
in
7.6%
of
(KMCH)
in
annually
outpatients. That is seems logical as
Thrombocytosis seen in 6.8 % of the
occur
person
children
.
mined (15).
Conclusion :
anemia,
thrombocytosis
leucocytosis,
and
seen in inpatients
more than outpatients ,leucopenia seen
in outpatients more than inpatients
,thrombocytosis show near results for
in and out patients but a little higher
for inpatients.
which is very near to our
(8)
.
Thrombocytopenia which is defined
as platelet less than 150× 103 per µL .
It is often discovered incidentally on
complete blood picture test
patient
with platelet count greater than 50×103
per µL rarely have symptoms. Platelets
count from 30 to 50 × 103 per µL
rarely manifest as purpura.
A
count from 10 to 30 may cause
bleeding with minimal trauma .A
platelets count less than 5 may cause
spontaneous bleeding in the current
study 8% of hospitalized patients seen
to be thrombocytopenic .this include
all thrombocytopenia below 150× 103
which have so many reasons. all the
literatures consider ITP as the main
51
References
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Fischbach
FT,
Dunning
MB.
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Manual of Laboratory and Diagnostic
Ferreira
Tests, 8th ed. Philadelphia: Lippincott
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Williams and Wilkins.2009
dos
Santos,.
Rev
Bras
7. Mark A, Marinella MD. Infectious
2. Susumu I , Robert J Arceci.
disease. Leukocytosis and leucopenia.
Pediatric
http://www.
Acute
Anemia.
http://emedicine.medscape.com/article/954
antimicrobe.org
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8. Chen HL, Chioou SS, Sheen JM.
3. WHO. Worldwide Prevalence of
Anemia 1993-2005: Global Database
ON Anemia. Geneva :WHO;2008.
Regil LM, et al. Global, regional, and
trends
in
hemoglobin
concentration and prevalence of total
and severe anemia in children and
pregnant and non-pregnant women for
1995-2011: a systematic analysis of
population-representative
data.
medical center of southern Taiwan.
Acta
4. Stevens GA, Finucane MM, De-
national
Thrombocytosis in children at one
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Lancet Global Health 2013; 1(1):
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Paediatrca
Tiawinaca1999
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40(5):309-313.
9. Carol Briggs ,Barbara J.Bain. Daicie
and
Lewis
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Hematology
Hematological
Techniques
Eleventh Edition .2012
10. Buseri FI, Siaminabo IJ, Jeremiah
ZA, Reference values of hematological
indices
of
infants,
children,
and
adolescents in Port Harcourt, Nigeria,
5. Firdose S, Siddaraju P. Anemia
July 2010 Volume 2010:2
among hospitalized children at a
65—70.
multispecialty
11. Alexander H, Judith K, Benjamin
hospital,
Bangalore.
India. Journal of family medicine and
M,
primary care .2014 Jan-Mar;3(1):48-53
Haematological
6. Eliane S. , Campos G, Emídio C.
de Albuquerque, Ilma K, Grande de
Arruda, Prevalence of anemia in under
five-year-old children in a children's
Peter
GK,
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Pages
Bertrand
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;volume 16 (3) pp 343–348
52
12.
Chris
Higgins.
Understanding
laboratory investigations: a guide for
nurses,
midwives
and
healthcare
professionals’ .third edition. Part three
Hematology
tests.2013.Wiley-
Blackwell publication
Correspondence to:
Dr.Rasha Tariq Jawad
Manager of the Hematology Unit,
Laboratory Department / Central Child
Teaching Hospital, Baghdad, Iraq.
13. Rachoin JS, Cerceo E, Milcarek B,
Hunter K, Gerber DR Prevalence and
impact of anemia in hospitalized
patients.
South
Med
J.
2013
Mar;106(3):202-6.
14. Rehemah. Simbauranga, Erasmus
kamugisha.
Prvalence
and
factors
associated with severe anemia amongst
under 5 children at bugando medical
center
,mwanza,
tanzania.
BMC
Omack
WA..
Hematology.2015.
15.
Ropert
guaer.
Thrompocytopenia. American Family
Physicion. Medical Center Family
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carolina. 2012 march15; 85(6): 612622
53
‫‪.Rasha Tariq Jawad , Ebtehal Ali Hussien‬‬
‫‪The results analysis of complete blood count‬‬
‫تحليل نتائج تعداد الدم الكامل خالل النصف األول من عام ‪ 5102‬في مستشفى الطفل المركزي‬
‫التعليمي في بغداد‬
‫رشا طارق جواد ‪ ، 1‬ابتهال علي حسين ‪2‬‬
‫‪ / F.I.C.M.S /M.B.Ch.B / MD0‬اختصاص امراض الدم المختبري ‪ ،‬مدير وحدة أمراض الدم‪ ،‬قسم‬
‫المختبرات ‪ /‬مستشفى الطفل المركزي التعليمي في بغداد‪ ،‬العراق‪.‬‬
‫‪ ،BMLT 5‬فني مختبري ‪ /‬وحدة أمراض الدم‪ ،‬قسم المختبر ‪ /‬المستشفى الطفل المركزي التعليمي في بغداد‪،‬‬
‫العراق‪.‬‬
‫الخلفية‪ :‬تعداد الدم الكامل (‪ ) CBC‬هو االكثر طلبا عادة كتحليل دم من قبل األطباء‪ .‬المستشفى التعليمي الطفل‬
‫المركزي هو ثاني أكبر مستشفى لألطفال في العراق‪ .‬نستعرض نتائج ‪ CBC‬للنصف األول من عام ‪ 5102‬في‬
‫المستشفى‪.‬‬
‫هذه‬
‫األهداف‪ :‬تم ترتيب هذه الدراسة الستكشاف مدى انتشار فقر الدم‪ ،‬فرط الكريات البيض‪ ،‬نقص الكريات البيض‪،‬‬
‫كثرة الصفيحات‪ ،‬نقص الصفيحات الدموية‪ ،‬وذلك باستخدام المحلل اآللي ‪ CBC‬لمرضى العيادة االستشارية‬
‫التوالي‪.‬‬
‫على‬
‫للمستشفى‬
‫الداخلين‬
‫والمرضى‬
‫المرضى والطرق‪ :‬دراسة استعادية‪ ،‬كان ما مجموعه ‪ 04390‬مريض حضورا المستشفى التعليمي المركزي‬
‫(من ‪ 0‬يناير من ‪ 0‬يوليو) لكل واحد منهم تم اجراء اختبار صورة الدم باستخدام روبي ابوت المحلل التلقائي‪.‬‬
‫وحضر ‪ 9753‬المرضى إلى العيادة الخارجية‪.‬‬
‫‪ 09901‬من المرضى كانوا داخلون للردهات‬
‫النتائج‪ :‬تم تحليل النتائج على النحو التالي‪ :‬فقر الدم‪ ،‬فرط الكريات البيض‪ ،‬نقص الكريات البيض‪ ،‬كثرة‬
‫الصفيحات‪ ،‬نقص الصفيحات الدموية للمرضى كلهم وعن كل شهر للمرضى الراقدين بحيث تكون تحليل النتيجة‬
‫وفقا للموسم‪ .‬فقر الدم كان أكثر شيوعا في المرضى المنومين (‪ )٪74 ،31‬من العيادات الخارجية (‪.)٪1 ،51‬‬
‫واعتبر نقص الكريات البيض أكثر في العيادات الخارجية (‪ )٪02 ،07‬من المرضى المنومين في (‪ ،)٪1،0‬في‬
‫حين أن زيادة عدد الكريات البيضاء أظهرت أن (‪ )٪01.1‬من المرضى المنومين و‪ ٪5‬من العيادات الخارجية‪.‬‬
‫كان نقص الصفيحات (‪ )٪1.3‬من المرضى الداخليين و (‪ )٪3.0‬من مرضى العيادات الخارجية‪ .‬وفيما يتعلق‬
‫اإلصابة الشهرية وجدنا أن أعلى نسبة فقر الدم لدى مرضى العيادات الخارجية شهدت في مايو (‪ ،)٪95‬في حين‬
‫كان ينظر إلى أدنى مستوى في كانون الثاني (‪ .)٪04.71‬فرط الكريات البيض والصفيحات سواء أظهر أعلى‬
‫التوالي‪.‬‬
‫على‬
‫‪)٪02.54‬‬
‫(‬
‫(‪،)٪04.71‬‬
‫الثاني‬
‫كانون‬
‫في‬
‫نسبة‬
‫الخالصة‪ :‬فقر الدم‪ ،‬فرط الكريات البيض‪ ،‬وكثرة الصفيحات شوهدت اكثر في المرضى المنومين من العيادات‬
‫الخارجية‪ ،‬نقص الكريات البيض شوهدت اكثر في العيادات الخارجية من المرضى المنومين‪ ،‬كثرة الصفيحات‬
‫‪.‬‬
‫للداخلين‬
‫طفيفة‬
‫زبادة‬
‫مع‬
‫للمجموعتين‬
‫النتائج‬
‫متقاربة‬
‫;كانت‬
‫كلمات البحث‪ :‬تحليل‪ ،CBC ،‬األطفال‬
‫‪54‬‬
Original article
Distribution of red cell antigens according to ABO, Rh and other rare blood
group systems in Kurdish ethnicity
Hisham A. Getta¹, Shaema S.Amin², Najmaddin Khoshnaw ³ * & 4, Belal A. Muhammad5 & 6
¹Department of Hematopathology, faculty of sciences, school of medicine, university of Sulaimani, Kurdistan
region, Iraq
²Department of Hematopatholgy, Internal Teaching Hospital, Sulaymaniyah, Kurdistan Region, Iraq
³*Department of Hematology, Hiwa Hospital, Sulaymaniyah, Kurdistan Region, Iraq
4
Kurdistan Board of Medical Specialties, Clinical Hematology/Trainee, Ministry of higher education and scientific
research, Erbil, Kurdistan Region, Iraq
5
Department of Medical Laboratory Techniques, Technical Institute of Halabja, Sulaimani Polytechnic University,
Sulaymaniyah, Kurdistan region, Iraq
6
Department of Medical Laboratory Sciences, College of Science, Komar University of Science and Technology,
Sulaymaniyah, Kurdistan region, Iraq
Received 23/11/2015
accepted 17/1/2016
55
Distribution of red cell antigens according to ABO
Hisham A.G, Shaema S.A, Najmaddin Kh.,Belal A.M
Abstract:
Background: Among more than 30 blood group systems, nine of them namely ABO, Rh, Kell, Kidd,
Duffy, MNS, P, Lewis and Lutheran are considered to be clinically significant. The distributions of these
blood groups are different between populations across the world. Studies about the frequency of blood
groups in Kurdish ethnicity are very limited in the literature.
Objectives: to explore the distribution of red cell antigens and phenotypes of various blood groups
among Kurdish population using different systems.
Materials and Methods: five thousand blood donors attending the central blood bank of Sulaymaniyah
province were randomly selected and tested for ABO and Rh antigens (D, C, c, E, & e) by using tube
method. 500 donors were randomly selected and further analyzed using other blood group systems.
Results: In the ABO system, the most common phenotype was O (37%), followed by A (32.6%), B
(22.8%) and AB (7.6%). Among the Rh blood group antigens, e was the most common (95.2%) followed
by D (91.3%), C (74.8%), c (69.4%), and E (30.6%) with DCe/DCe(R1R1) and dce/dce(rr) being the
most common phenotypes among Rh-D+ve and Rh-D-ve groups, respectively. The most common
phenotypes for other blood systems were as follow; Kell(K-k+,94%), Kidd(jk a+b+,44.5%), Duffy(fy
a+b+,45%), Lutheran(Lu a-b+,92%), Lewis(Le a-b+,54.5%), P(P1,76%), MNS(M+N+S-s+,40%)
Conclusion: the various red cell antigens recorded by different blood grouping systems in this study was
intermediate between the European and Asian countries with some specificity to the Kurds population
reflecting the distinct geographical area and preserved ethnic background of the Kurds in the region.
Keywords: ABO, Rhesus (Rh), red cell antigen, Kurdish ethnicity.
56
Introduction:
The ABO and Rhesus (Rh) blood group
are more immunogenic and active at body
systems are among the most clinically
temperature (8)
important discoveries of the last century in
The ABO blood group antigens are encoded
the field of hematology. The ABO blood
by one genetic locus, the ABO locus, which
group system was first discovered by
has three alternative (allelic) forms A, B,
Landsteiner in 1901(1). Later a joint work of
and O, located on the long arm of
the same author with Wiener resulted in the
chromosome 9
discovery of Rhesus (Rh) blood grouping
pattern is the four well defined blood groups
system in 1940
(2)
(9)
. The result of this genetic
. In these systems, the
(A, B, AB, and O). The Rh system is the
determination of blood groups is based on
most polymorphic and the most clinically
certain inherited antigenic substances on the
significant blood group system beside the
surface of red blood cells (RBCs)
(3)
. These
ABO system. Currently it is composed of 50
antigens have found to play crucial roles in
antigens associated to genes located on
several clinical areas such as in transfusion
chromosome 1 including RhD, RhC, RhE,
medicine,
Rhc and Rhe which represents the most
organ
transplantation,
(10,11)
autoimmune hemolytic anemia (AIHA),
important Rh antigens
fetomaternal blood group incompatibility,
studies have shown that the frequency of
paternity
allelic distribution of the ABO/Rh blood
identification,
and
forensic
. However,
medicine (4-6)
group varies among different geographical
According to the International Society of
areas and also between populations with
Blood Transfusion (ISBT), there are now
different ethnic background across the
more than 270 antigens distributed over 30
world. This is probably due to the genetic
distinct blood group systems [1, 7]. Nine of
polymorphism nature of the ABO/Rh genes.
these systems namely ABO, Rh, Kell, Kidd,
Clinically speaking, blood transfusion is a
Duffy, MNS, P, Lewis and Lutheran are
lifesaving process for some patients, yet it is
considered
important.
not free from transfusion-related risks such
Among them, the ABO and Rh systems are
as transfusion transmissible diseases (TTD)
the most important systems during blood
and alloimmunization
transfusion due to the fact that their antigens
determine
to
be
clinically
the
(12)
.It is crucial to
phenotype
of clinically
57
significant blood group antigens on the
information is very limited regarding the
donor RBCs especially in situations when
extended population blood groups especially
alloimmunization is particularly undesirable.
using systems other than the ABO/Rh blood
Examples of this include young females,
groups. In the present study we, for the first
pregnant women, and patients who are
time, determined the extended red cell
expected
blood
antigens and phenotype frequencies of
transfusion in their life such as in patients
various clinically significant blood groups
that have thalassemia, sickle cell anemia,
amongst regular healthy Kurdish voluntary
cancer, dialysis, etc.
blood donors in Sulaymaniyah province.
Racial differences in blood group antigen
This study provides valuable information
distribution are common between different
about the normal distribution of different
populations across the world. Available data
blood groups among the Kurdish population
in the literature have relatively clarified the
and it can be used to establish a foundation
genotype/phenotype
of donor database for different RBC
to
require
repeated
variation
of
blood
group systems in the European, American
antigens.
and some Asian countries. However, such
information in developing countries is still
limited. Kurdish population are normal
inhabitants of the northern part of Iraq
(called Kurdistan or Kurdistan region of
Iraq) where only ABO and Rh (D) status of
blood donors and recipients are taken into
account for compatibility testing. A part of
two recent regional studies about the
ABO/Rh blood group systems (13,14)
58
Materials and methods:
Study Design:
Sample collection and methods:
This work is a cross-sectional study carried
Blood samples were collected in ethylene
out from 1st of June to 30th of September
diamine tetra acetic acid (EDTA) tubes and
2014 in the Central Blood Bank of
analyzed
Sulaymaniyah province/Iraq. The study was
detection using acryl amide gel technique
conducted after taking approval from blood
following the manufacturer’s instruction.
bank and informed consent from blood
This system uses ID card “DiaClon ABD-
donors for their participation in the present
Confirmation for Patients” which contains
study.
monoclonal anti-A, B and D within the gel
Donor Selection:
matrix
freshly
for
(Bio-Rad
ABO/Rh antigen
Laboratories,
DiaMed
Switzerland). A small portion (3-5%) of the
A total of 5000 healthy regular voluntary
blood donors (aged between 18-60 years)
were included in this study. All the donors
were subjected to red cell antigen typing
using ABO/Rh (D) blood group antigen
systems. Out of them, 500 donors were
randomly selected for further antigen typing
using other Rh blood group antigens
including C, c, E, and e. In addition, 400
donors were also randomly selected for
extended antigen typing using other blood
group systems including Kell (k-cellano),
Kidd (Jka, Jkb), Duffy (Fya, Fyb), MNSs
(M, N, S, s), Lewis (Lea, Leb), Lutheran
(Lua, Lub) and P (P1).
RBCs suspended in isotonic saline solution
was further analyzed by Direct Antiglobulin
Test (DAT) according to standard protocols.
The DAT negative samples were further
typed for extended antigen profiling through
antigen-antibody agglutination method using
kits supplied by Rapid Labs Limited,
England
following
the
manufacturer’s
guidelines. The ABO and Rh (C, c, E & e)
antigen
detection
were
performed
indirect
Antiglobulin Technique
by
(IAT),
using monoclonal IgG antisera [15]. The
tests are interpreted depending on the
finding of the agglutination which are
graded as 1+ to 4+ positive, or negative
which indicating the absence of the of
corresponding antigen.
59
Results:
The results of the ABO system showed that
and Rh (D) negative groups, respectively
the most common blood group was O
(Table 3).
(37.0%), followed by A (32.6%), B (22.8%)
The frequency of red cell antigens of Kell,
and
Kidd, Duffy, MNS, Lutheran, Lewis and P
AB
(7.6%).
The
results
also
demonstrated that the majority of donors
blood
were positive for Rh (D) antigen (91.26%)
(supplementary Table 2) and the phenotype
while minority (8.74%) were negative based
frequencies of these systems are presented in
on the Rh blood group system (Table 1).
(supplementary Table 3). According to the
The frequency of the ABO phenotypes
Kell blood group system K-k+ was the most
associated to the Rh (D) phenotype was as
common phenotype (94.2%) in our donors
follow: for the Rh (D) positive individuals;
and no K+k- & K-k- phenotypes were
group
systems
are
shown
in
+ve
the most common blood group was O
+ve
(33.2%), followed by A
(21.1%), and AB
+ve
observed in any donors. In the Kidd system,
+ve
(29.8%), B
Jk (a+b+) was predominant (44.5%) and no
(7.1%). While for the
Jk (a-b-) was observed. Jka and Jkb antigens
Rh (D) negative individuals the ratio was
were determined in (77%) and (67.5%) of
-ve
-ve
3.8%, 2.7%, 1.7%, and 0.5% for O , A ,
-ve
B , and AB
1).
-ve
groups respectively (Table
Furthermore,
our
showed Fy (a+b) as the most common
also
phenotype (45%). The Duffy null or Fy (a-b-
demonstrated that the e antigen had the
) phenotype was observed in (4%) of donors,
highest frequency (95.2%), followed by D,
while Fya and Fyb antigens were observed
C, c & E antigens (91.26%, 74.8%, 69.4% &
in
30.6%, respectively)
respectively. In the Lutheran blood group
as
results
donors, respectively. The Duffy system
shown
in
(Table 1 & 3).
(72%)
and
(51.5%)
of
donors,
system, the most common phenotype was
Our phenotypic studies suggest that eight
Lu (a-b+) (92%). Lua and Lub antigens
probable phenotypes are possibly found in
were observed in (4.5%) and (95.5%) of
our population. Among them, the DCe/DCe
donors, respectively, while, null phenotype
(R1R1), and dce/dce (rr) were the most
Lu (a-b-) was determined in (3.5%). The
common phenotypes among Rh (D) positive
predominant phenotype of the Lewis system
was Le (a-b+) (54.5%). Lea and Leb
60
antigens were observed in (43.5%) and
Some variations may even occur in different
(64.5%)
areas within one small country
of
donors,
respectively.
(16)
. Despite
Approximately, (76%) of donors were
the fact that the antigens involved are stable
shown to be positive for P1 antigen. Finally,
throughout life, the resultant polymorphism
in the MNSs blood group system, (33.5%)
remains important in population genetic
of donors were homozygous for M antigen
studies,
(M+N-),
were
compatible blood, evaluating the probability
homozygous for N antigen (M-N+). Blood
of hemolytic disease in the newborn,
groups (M+N+) and (S-s+) were the most
resolving disputes in paternity/maternity and
common
for forensic purposes (17).
while
only
phenotype
20.5%
with
the
same
estimating
the
availability
of
percentage (46%) and no S-s- phenotype
In this study, we examined the RBC
was found. Out of nine possible phenotypes,
antigens and phenotype frequencies of the
(M+N+S-s+)
common
ABO and Rh blood groups in local donor
phenotype (40%), whereas (M-N+S+s-) was
population of Sulaymaniyah province (The
the
(0.5%)
northern part of Iraq) using different blood
observed in the MNS blood group system of
group systems. All the donors were males
least
was
common
the
most
phenotype
the current study (supplementary Table 3).
and belong to well-known Kurdish tribes
living in the city and surrounding area. Our
Discussion:
results indicated that the blood group O was
The knowledge of prevalence of various
blood
group
antigens
and
phenotype
frequencies in the local donor population is
important in transfusion services especially
in areas of antenatal serology, paternity
testing, and selecting compatible blood in
problem transfusions (24).
The ABO/Rh blood group system:
It is well established that ABO and Rh
genotypes and phenotypes vary widely
across races and geographical boundaries.
the most frequently encountered phenotype
(37.0%) followed closely by the blood group
A (32.6%), then B (22.8%), and the lowest
one was AB (7.6%). The results also
demonstrated that the majority of donors
were positive for Rh (D) antigen (91.26%)
while minorities (8.74%) were negative.
These results are in agreement with the
general trend of the ABO blood groups (O >
A > B > AB) and Rh (Rh+ve > Rh-ve)
recorded for the Kurdish population in
61
(13,14)
northern Iraq (Erbil and Duhok city)
,
and E (25.1%)] and a part from D, the
Arabian population lives in Iraq and some
frequency of other Rh antigens was in
other neighboring countries
(18-21)
. However,
agreement with observation of Mashaali in
variation between the frequencies of the
Baghdad in which the frequency of e, C, c
blood groups is observed (supplementary
and E were (94%, 77%, 67% and 32 %,
Table 4). This variation may due to
respectively)
differences in the geographical area and
are the only two studies available for
racial background. Similar results were also
comparison in Iraq.
observed in populations of other ethnicity
Comparing to the neighboring countries of
such
as
Caucasian
(34)
Europeans
(33)
, Blacks
(14-19)
. To our knowledge, these
and
Iraq, the results of the current study are
. On the other hand in many
comparable with studies performed in
Asian populations, there is an increase in the
northeast of Iran
prevalence of group B, e.g. India and
(2012). However, apart from e antigen, the
Malaysia
(22,23)
comparable
. Our results were not
to
that
neighboring Turkey
(24)
reported
in
, and Syria
(25)
(26)
and Bahrain (Jenan YT
results were markedly different from that
the
reported in other countries such as north
, in
Indian (27) (see Table 4).
which higher prevalence of group A was
reported (supplementary Table 3). The
lowest frequent phenotype of the ABO
system linked to the Rh (D) phenotype was
AB
-ve
(0.5%) which is similar to Jaff’s
observation in Erbil, a neighboring city
within the Kurdistan Region of Iraq (13).
A significant difference was observed in the
frequency of C, E c, and e antigens when
donors were categorized as D+ve and D-ve. In
D+ve donors the distribution of C and E
antigens
was
(81.7%
and
34.2%,
respectively) while in D-ve donors was (17%
and 0%) (P < 0.05), suggesting that C and E
Regarding the frequency of Rh antigens (D,
antigens are more prevalent on D+ve red
C, c, E and e), we found that the e antigen
cells. In contrast, the c and e antigens were
has the highest frequency (95.2%), followed
detected in almost all D -ve donors (100%) as
by D (91.3%), C (74.8%), c (69.4%) and the
compared to the less frequency occurrence
lowest frequent antigen was E (30.6%). This
in D+ve donors (65.8% and 94.6% for c and e
observation is very close to the results of a
respectively) (P < 0.05). These results are in
recent study performed in Duhok city [e
accordance with a study in north Indian
(95.6%), D (91.1%), C (75.9%), c (68.1%)
62
(26)
population in which the frequency of C and
Iran
E antigens in D+ve donors were massively
respectively), but higher than Blacks (2%)
higher than their presence among D-ve
(29)
donors, while the prevalence of c and e was
antigen was detected in almost (100%) in
in contrast
(27)
and
Whites
(8%,
and
9%,
. In contrast, frequency of k (Cellano)
. Moreover, these results are
our donor population, which is similar to the
further supported by our observation that
results reported in north Indian 100%
DCe/DCe (R1R1) was the most common
(Thakral et al. 2010), and black populations
phenotype (34%), followed by DCe/dce
100%
(R1r) (29.6%) and DCe/DcE (R1R2), and
obtained from Whites and northeast-Iran
+ve
donors, while the
who showed negative results for k (Cellano)
dce/dce (rr) found to be the most common
antigen by 0.2%, 2.3% respectively. This
phenotype (83%) in D-ve donors (see Table
implies that while Whites and northeast
4). This genotype pattern shows strong
Iranian
similarities to that reported in northeast Iran
develop anti-k (Cellano), the likelihood of
and some similarities to north India and
finding this alloantibody in our population is
Caucasians population. However, the pattern
negligible (Table 5).
(18.3%) in our D
was far different from what reported in
Blacks as shown in (Table 4).
Other blood group systems:
The Kell Blood Group System:
(29)
, but differ from the results
population
Regarding
the
might
distribution
occasionally
of
Kell
phenotypes, the most common phenotype
was found to be K-k+ (94.2%), followed by
K+k+ (5.8%). None of the donor was found
to be K homozygous (K+k-) or (K-k-).
The K antigen is very immunogenic (second
to the D antigen) in stimulating antibody
production. Anti-K is an important antibody
as it is nearly always immune, IgG, and
complement-binding. It causes severe HTRs
and HDFN
(28)
. Its frequency in this study
was low (5.8%), which is similar to that of
These results are similar to that reported in
north Indian population recorded by two
independent studies
(27,30)
. Again our results
were found to be intermediate between
Whites/northeast of Iran from one side
and the Black population from another side
(29)
(Table 5).
Thakral et al. study in north India (5.56%)
(27)
, and it occurs between the frequencies
reported by Keramati et al. in northeast of
(26)
63
The Kidd Blood Group System:
86.75%, 66%, respectively. While the
The frequencies of Kidd blood group system
frequency of Fyb antigen is much closer to
antigens (Jka = 77%, Jkb = 67.5%) observed
that reported by Thakral et al. (56.15%), and
in this study was similar to those in
it is in between Keramati et al. study and
northeast of Iran
(26)
, and comparable to that
of Whites (Beadling & Cooling, 2007), and
north-Indian population
(27)
, while there was
Whites
(49.2%,
respectively).
However, again our results showed much
higher percentage of Duffy antigen than the
(Fya = 10%, Fyb = 23%)
a remarkable difference with the Black
Blacks
population (Jka = 92%, Jkb = 49%)
(Table 6).
(29)
83%,
(29)
(Table 5).
In this system, Fy (a+b-) was the most
The most common Kidd phenotype was Jk
common phenotype in our study was
(a+b+) (44.5%), which is similar to those in
(38.5%), which is comparable to the results
(26)
northeast of Iran
north India
(27)
, and comparable to
and Whites
(29)
(49.21 % and
reported in north-India
Iran
(26)
,
which
are
(27)
and northeast of
(43.9%,
47.4%,
49%, respectively), while much higher than
respectively). However, it is much higher
what recorded for Blacks (34%). The Jk
than Whites (17%) and Blacks (9%)
(a+b-) is found to be the most common
population
phenotype among the Blacks (57%)
(29)
. No
(29)
. The most common reported
phenotype in Whites is Fy (a+b+) 49%, and
Jk (a-b-) phenotype was detected in any
in Blacks is Fy (a-b-) (68%) [29].
donor, which is also very rare in White and
Duffy antigen is postulated to be the
Black people, except for Polynesians (< 1%)
receptor for entry of the plasmodium vivax
(29)
on the red cells (31,32). This probably explains
(Table 5).
high prevalence of Duffy null phenotype Fy
The Duffy Blood Group System:
The frequencies of the Duffy blood group
system
antigens
were
(Fya
=70%,
Fyb=57.5%). The Fya antigen frequency is
very close to that reported in northeast of
Iran (73.8%)
(26)
, and it is intermediate
between results reported in north Indian
population
(27)
, and Whites
(29)
, which are
(a-b-) in the endemic area of malaria such as
among the black people (68%)
(29,33,34)
. The
frequency of Duffy null phenotype Fy (a-b-)
in our study was (4%), which is very close
to that reported by Keramati et al. in
northeast of Iran (3.4%)
(26)
. While it is very
rare in Whites (Beadling & Cooling, 2007)
64
(27)
while in Thakral et al. study the most
(Table 6). This higher rate of null phenotype
common phenotype was M+N- and S+s+
frequency in our donors might be related to
(Table 6).
the existence of endemic areas of malaria in
Out of nine possible phenotypes found in
the Kurdistan Region of Iraq in the past.
our study, M+N+S-s+ (40%) was the most
The MNSs Blood Group System:
common phenotype; whereas, M-N+S+s-
The frequencies of the MNSs blood group
(0.5%) was the less common phenotype
system antigens M, N, S and s in our study
observed in the MNS blood group system.
were 79.5%, 66.5%, 54%, and 88.5%,
The frequency of M+N+S-s+ in this study,
respectively. These results are similar to the
is comparable to the results reported by
results reported in north Indian population
Agarwal et al. in India (28.8%) (Agarwal et
(75.4%, 61.5%, 56.5%, and 87.4% for M, N,
al. 2013), as well as in Europeans (22.6%)
S and s respectively) (27). The results are also
and African-Americans (33.4%) (35,36), while
comparable
in Thakral study in north Indian population
and (0%) in north Indian population
with
the
observation
of
Keramati et al. in northeast of Iran (87%,
56.7%, 56.7%, and 84.5%, respectively)
(26)
,
and Whites (78%, 72%, 55%, and 89%,
respectively), while they are different with
the
most
common
phenotype
was
M+N+S+s+ (19.6%) (Table E).
Conclusions:
what recorded for Blacks, particularly for S
The knowledge of these antigen and
and s antigen frequencies (29) (Table 6).
phenotype frequencies is crucial in the
Regarding the phenotype frequency, M+N+
and S-s+ were the most common phenotypes
observed in the MNS blood group system in
our study which were nearly equal (46%) to
each other. These results are comparable to
that of Keramati et al. study who reported
that M+N+ and S-s+ are the most common
phenotypes (43.7% and 43.3%, respectively)
(26)
. The results are also comparable to that
reported in White and Black populations(29),
clinical field. Based on this information, one
can predict the common alloantibodies that
could be happened in pregnant women and
patients receiving blood transfusions. For
instance, E antigen frequency in our donor
population was the lowest (30.6%), followed
by c antigen (69.4%) in ascending order of
frequency. Thus, it can be assumed that the
most common alloantibodies in Rh blood
group system among pregnant women and in
patients receiving blood transfusion would
65
be anti-E and then anti-c. Another advantage
Sulaymaniyah for their valuable help and
of
coordination in completing this research.
knowing
antigen
and
phenotype
frequency is that it helps in selection of
antigen negative blood units for patients
Authorship contributions:
For
HAG have designed the research and shared
example, if a patient in our population has
in writing the article, SSA did all laboratory
alloantibody against C and needs two units
work and shared in writing the article, NK
of blood, a minimum of 8-10 units of ABO
reviewed and shared in writing editing, and
and Rh (D) matched blood units will need to
designing the article. BAM reviewed the
be tested for C antigen to find two units of
article, redesigned the paper, and did major
antigen negative blood (since C antigen
editing of all parts of the writing, also
negative donors form about 25% of all our
submitted the paper.
with
pre-formed
alloantibodies.
donor’s population). This notion is also
Conflict of interest:
applied to the less common blood group
All authors declares that there is no conflict
systems included in this study.
of interest.
Over all, the various red cell antigens
recorded
by
different
blood
grouping
systems in this study was intermediate
between the European and Asian countries
with
some
population
specificity
reflecting
to
the
the
Kurds
distinct
geographical area and preserved ethnic
background of the Kurds in the region.
Acknowledgment:
We have special thanks to the ministry of
health of Kurdistan region and the health
directorate of Sulaymaniyah governorate.
We also thank the director and all laboratory
staff of the central blood bank of the
66
Tables
Table 1: Distribution of ABO and Rhesus (Rh) blood groups both individually (upper panel) and in combination
(lower panel). Upper panel, the total number of donors and the percentage of each group is given. The most common
ABO blood group was O (37.0%), followed by A (32.6%), B (22.8%) and AB (7.6%). Most of the donors were positive
for Rh (D) antigen (91.26%) and minority (8.74%) were negative. Lower panel, the number and percentage of donors for
each blood group is given. The total number of donors also provided. In both Rh+ve (left) and Rh-ve (right) groups the most
common ABO blood group was O, followed by A, B, and AB as indicated regardless of the presence/absence of Rh
antigen. N = 5000.
Blood groups
Number of donors
Percentage (%)
O
1850
37
A
1630
32.6
B
1140
22.8
AB
390
7.8
Rh (D) positive (Rh+ve)
4550
91.3
Rh (D) negative (Rh-ve)
435
8.7
ABO/Rh (D) positive (Rh+ve)
ABO/Rh (D) negative (Rh-ve)
ABO blood groups
Rh (D) blood groups
Blood
groups
Number & (%) of donors
Blood
groups
Total number of
Number & (%) of donors
donors
O+
1662 (33.2)
O-
190 (3.8)
1852 (37.0)
A+
1491 (29.8)
A-
137 (2.7)
1628 (32.6)
B+
1055 (21.1)
B-
84 (1.7)
1139 (22.8)
AB+
355 (7.1)
AB-
26 (0.5)
381 (7.6)
Total
4563 (91.3)
437 (8.7)
5000 (100%)
67
Tables
Table 2: Distribution of other Rh antigens (C, c, E, and e) and phenotypes. A) The number and percentage of donors
for each blood-group antigen is given. The most common antigen was e (95.2) followed by C (74.8), c (69.4), and E
(30.6). B) The Rh phenotype in Rh (D) positive (Rh+ve) donors. C) The Rh phenotype in Rh (D) negative (Rh-ve) donors.
The most common Rh phenotype was R1R1 (DCe/DCe) (34%) in Rh+ve donors, while rr (dce/dce) was the most common
phenotype (83%) among Rh-ve donors. N = 500.
Number of positive donors
Percentage of positive donors
C
374
74.8
E
153
30.6
c
347
69.4
e
476
95.2
A) Rh Antigens
B) Phenotypes in Rh (D) positive (Rh+ve) donors
R1R1 (DCe/DCe)
152
34
R1r (DCe/dce)
132
29.6
R1R2 (DCe/DcE)
82
18.3
R2r (DcE/dce)
47
10.5
R2R2 (DcE/DcE)
24
5.4
R0 r (Dce/dce)
10
2.2
C) Phenotypes in Rh (D) negative (Rh-ve) donors
rr (dce/dce)
44
83
rʹr (dCe/dce)
9
17
68
Tables
Table 3: Phenotype frequencies in systems other than ABO/Rh. Results of Kell, Kidd, Duffy, Lutheran, Lewis, P, and
MNSs blood group systems are presented in percentage as indicated, N = 400.
Blood group system
Kell system
Kidd System
Duffy System
Lutheran system
Lewis system
P system
MNS System
Phenotype
K-k+
K+k+
Jk (a+b+)
Jk (a+b-)
Jk (a-b+)
Fy (a+b-)
Fy (a+b+)
Fy (a-b+)
Fy (a-b-)
Lu (a-b+)
Lu (a+b+)
Lu (a-b-)
Lu (a+b-)
Le (a-b+)
Le (a+b-)
Le(a+b+)
Le (a-b-)
P1
M+N+
M+NM-N+
S-s+
S+s+
S+sM+N-S+sM+N-S+s+
M+N-S-s+
M+N+S+sM+N+S+s+
M+N+S-s+
M-N+S+sM-N+S+s+
M-N+S-s+
Donors (%)
94.2
5.8
44.5
32.5
23
38.5
31.5
26
4
92
3.5
3.5
1.0
54.5
33.5
10
2
76
46
33.5
20.5
46
42.5
11.5
5.5
19
18
22.5
17.5
40
0.5
6
14.5
69
Tables
Table 4: Frequencies of Rh phenotypes. The observed Rh phenotype of the present study compared to the published
data of other countries as indicated.
Northeast Iran2
Present study (%)
North-India1 (%)
DCe/DCe (R1R1)
30.4
35.2
25
18.5
2.0
DCe/dce (R1r)
26.4
30.7
31.8
34.9
21.0
DCe/DcE (R1R2)
16.4
8.1
16.5
13.3
4.0
DcE/dce (R2r)
9.4
5.9
9.6
11.8
18.6
DcE/DcE (R2R2)
4.8
0.7
1.7
2.3
0.2
2
2.2
4.2
2.1
45.8
dce/dce (rr)
8.8
0.3
8.3
15.1
6.8
dCe/dce (rʹr)
1.8
2.5
1.3
0.8
Rare
Phenotypes
Dce/dce (R0r)
1
: Sarkar et al. 2013
2
: Keramati et al. 2011
(%)
Caucasian3 (%)
3
: Reid & Lomas-Frances, 2004
70
Black3
(%)
Tables
Table 5: Phenotype frequencies of the Kell and Kidd blood group systems. Antigen frequencies (%) of Kell and Kidd
blood group systems are compared with other published results as indicated. The phenotype frequencies (%) of the Kidd
0.0
0.0
Present study
North-India
5.56
100
94.3
5.7
0.0
0.0
Thakral et al. 2010
97.7
96.0
4.0
0.0
0.0
(%)
(k) (%)
(%)
North-India
K+k-
5.8
(%)
94.2
K+k+
100
(%)
5.8
K-k+
Sulaymaniyah-Iraq
Cellano
References
People groups
Kell (K)
K-k- (%)
blood group system was also compared.
2.3
0.0
Whites
9.0
100
91.0
8.8
0.2
0.0
98.0
2.0
Rare
0.0
Keramati et al. 2011
Beadling & Cooling,
2007
Beadling & Cooling,
2007
References
(%)
Jk
(%)
(%)
Jka (%)
People groups
Jkb (%)
2.0
Blacks
&Thapliyal,
1997
(a-b-)
5.7
Jk (a-b+)
92.0
Jk (a+b)
99.8
(%)
8.0
Jk (a+b+)
Northeast-Iran
Nanu
Sulaymaniyah-Iraq
77.0
67.5
44.5
32.5
23
0.0
Present study
Northeast-Iran
79.1
65.1
44.4
34.7
20.7
0.2
North-India
82.6
66.6
49.2
33.4
17.3
0.0
Thakral et al. 2010
77
74
49
28.0
23.0
Very rare
Whites
Beadling & Cooling,
2007
Blacks
92
49
34.0
57
9.0
Very rare
Beadling & Cooling,
2007
71
Tables
Table 6. Antigen and phenotype frequencies of Duffy and MNSs blood group systems. Antigen and
phenotype frequencies (%) of Duffy and MNSs blood group systems in this study compared with other
published results as indicated.
People groups
Fya
(%)
Fyb
(%)
Fy (a+b-)
(%)
Fy (a+b+)
(%)
Fy (a-b+)
(%)
Fy (a-b-)
(%)
References
SulaymaniyahIraq
70
57.5
38.5
31.5
26
4.0
Present study
Northeast-Iran
73.8
49.2
47.4
26.4
22.8
3.4
Keramai
2011
et
al.
North-India
86.7
56.1
43.8
42.9
13.3
0.0
Thakral
2010
et
al.
Whites
66
83
17.0
49.0
34.0
Very rare
Beadling
&
Cooling, 2007
Blacks
10
23
9.0
1.0
22.0
68.0
Beadling
&
Cooling, 2007
People groups
M
(%)
N
(%)
S
(%)
M+N+
%
M+N
-%
M-N+
%
S-s+
%
S+s+
%
S+s%
s
(%)
References
SulaymaniyahIraq
79.5
66.5
54
46
33.5
20.5
46
42.5
11.5
88.5
Present
study
North-India
75.4
61.5
56.5
43.7
43.3
13
43.3
41.2
15.5
87.4
Thakral et
al. 2010
Northeast-Iran
87
56.7
56.7
36.9
38.5
24.6
43.5
43.8
12.6
84.5
Keramati et
al. 2011
Whites
78
72
55
50
28
22
45
44
11
89
Beadling &
Cooling,
2007
Blacks
74
75
31
44
26
30
69
28
3
93
Beadling &
Cooling,
2007
72
Supplementary Data
Supplementary data:
Supplementary Table 2: Antigen frequencies of the Rh (D) blood groups. Results of the Rh
system of the present study compared to other parts of Iraq, neighboring countries and some other
populations as indicated.
Rh (D) +ve
Rh (D) –
%
ve %
Sulaymaniyah-Iraq
91.3
8.7
Present study
Erbil-Iraq
91.7
8.3
Jaff, 2010
Babylon-Iraq
90.1
9.9
Salih, 2009
Saudi Arabia
91.2
8.9
Al-Himaidi & Umar, 2002
Bahrain
91.1
8.9
Jenan, 2012
Arians (Pakistan)
91.7
8.3
Ali et al. 2005
Kuwait
92.5
7.5
Al-Bustan et al. 2002
Iran
90.2
9.8
India
93.4
6.6
Thakral et al. 2010
Baghdad-Iraq
80
20
Mashaali, 2014
Blacks
92
8
Whites
85
15
Asians
99
1
People groups
References
Beadling
&
Cooling,
2007;
Cooling,
2007;
Barclay, 2001
Beadling
&
Barclay, 2001
Reid & Lomas-Frances, 1997
73
Supplementary Data
Supplementary Table 3: Frequency of red cell antigens in systems other than ABO/Rh.
Results of Kell, Kidd, Duffy, MNSs, Lutheran, Lewis and P blood group systems are presented
both in absolute numbers and percentage as indicated, N = 400.
Antigens
Number
Percentage (%)
K
29/500
5.8
k
400/400
100
308/400
77
270/400
67.5
280/400
70
230/400
57.5
318/400
79.5
266/400
66.5
216/400
54
354/400
88.5
Kell
Kidd
Jka
b
Jk
Duffy
Fya
Fyb
MNSs
M
N
S
s
Lutheran
Lua
Lub
18/400
4.5
382/400
95.5
Lea
174/400
43.5
b
Le
258/400
64.5
P1
304/400
76
Lewis
P
74
Supplementary Data
Supplementary Table 3: Antigen frequencies of the ABO blood groups. Results of the ABO
system of the present study compared to other parts of Iraq, neighbour countries, and some
other populations as indicated.
People groups
O%
A%
B%
AB%
Sulaymaniyah-Iraq
37
32
23
8
present study
Erbil-Iraq
37
32
24
7
Jaff, 2010
Babylon-Iraq
36
28
28
8
Salih, 2009
Baghdad-Iraq
39
26
24
11
Mashaali, 2014
Iran
35
33
23
9
Boskabady et al. 2005
Iran
34
30
28
8
Kuwait
44
27
24
5
Al-Bustan et al. 2002
Saudi Arabia
51
26
19
4
Sarhan et al. 2009
Jordan
37
38
18
7
Hanania et al. 2007
Caucasian
47
41
9
3
Guyton & Hal, 2005
African blacks (e.g. Nigeria)
53
24
20
3
Enosolease & Bazuaye, 2008
European
43
40
12
5
Mollison et al. 1997
Asians (e.g. India)
39
23
33
5
Ali et al. 2005
Asian (e.g. North India)
32
22
37
9
Agrawal et al. 2013
References
75
Supplementary Data
Supplementary Table 4: Antigen frequencies of extended Rh blood groups (e, C, c, E).
Results of the extended Rh blood group system of this study compared to the published data of
other parts of Iraq and some other countries as indicated.
People groups
e%
C%
c%
E%
95.2
74.8
69.4
30.6
Baghdad-Iraq
94
77
67
32
Northeast-Iran
97.9
75.9
73.9
29.5
Bahrain
97.3
73.2
71
21
North-India
98.1
90.2
49.5
18.9
Sulaymaniyah-Iraq
References
Present study
Mashaali, 2014
Jenan, 2012
Thakral et al. 2010
Supplementary Table 5: phenotype frequencies of MNSs blood group system compared to
other published data as indicated.
Present study
(%)
•India (%)
*European (%)
*African
American (%)
M+N+S-s+
40
28.7
22.6
33.4
M+N+S+s+
17.5
20.9
22.4
13
M+N+S+s-
22.5
5.12
3.9
2.2
M+N-S-s+
18
13.8
10.1
15.5
M+N-S+s+
19
15
14
7
M+N-S+s-
5.5
7.1
5.7
2.1
M-N+S-s+
14.5
5.1
15.6
19.2
M-N+S+s+
6
3.1
5.4
4.5
M-N+S+s-
0.5
1.2
0.3
1.6
Phenotype
•(Agarwal et al. 2013)
* Lal et al. 2000; Cleghorn, 1960.
76
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79
‫توزيع مستضدات الخاليا الحمراء وفقا ل‪Rh ،ABO‬وغيرها من أنظمة فصائل الدم النادرة لدى قومية‬
‫الكورد العراقيين‬
‫هشام جيتا ‪، 1‬شيماء امين ‪ ،2‬نجم الدين خوشناو ‪ 3‬و ‪ ،4‬بالل محمد ‪5‬و‪6‬‬
‫‪ 1‬قسم امراض الدم‪ ،‬كلية العلوم‪ ،‬كلية الطب‪ ،‬جامعة السليمانية‪ ،‬إقليم كردستان‪ ،‬العراق‬
‫‪ 2‬قسم امراض الدم ‪ ،‬مستشفى الداخلية التعليمي ‪ ,‬السليمانية ‪ ,‬إقليم كردستان‪ ،‬العراق‬
‫‪ 3‬قسم أمراض الدم‪ ،‬مستشفى هيوا‪ ،‬السليمانية‪ ،‬كردستان‪ ،‬العراق‬
‫‪ 4‬مجلس كردستان للتخصصات الطبية والسريرية أمراض الدم ‪ /‬متدرب وزارة التعليم العالي والبحث العلمي‪ ،‬أربيل‪ ،‬إقليم‬
‫كردستان‪ ،‬العراق‬
‫‪ 5‬قسم تقنيات المختبرات الطبية‪ ،‬المعهد الفني حلبجة‪ ،‬جامعة السليمانية للفنون التطبيقية‪ ،‬السليمانية‪ ،‬إقليم كردستان‪ ،‬العراق‬
‫‪ 6‬قسم علوم المختبرات الطبية‪ ،‬كلية العلوم‪ ،‬جامعة كومار للعلوم والتكنولوجيا‪ ،‬السليمانية‪ ،‬إقليم كردستان‪ ،‬العراق‬
‫الخلفية‪ :‬من بين أكثر من ‪ 03‬نظام لفصائل الدم‪ ،‬تسعة منهم وهما ‪Lewis،P ،MNS ،Duffy ،Kidd ،Kell ،Rh ،ABO‬‬
‫و‪ Lutheran‬تعتبر هامة سريريا‪ .‬توزيعات هذه فصائل الدم تختلف بين السكان في جميع أنحاء العالم‪ .‬دراسات حول وتيرة‬
‫الطبية‪.‬‬
‫المراجع‬
‫في‬
‫للغاية‬
‫محدودة‬
‫الكردي‬
‫العرق‬
‫في‬
‫الدم‬
‫فصائل‬
‫األهداف‪ :‬الستكشاف توزيع مستضدات الخاليا الحمراء والظواهر من فصائل الدم المختلفة بين السكان األكراد باستخدام أنظمة‬
‫مختلفة‪.‬‬
‫المواد والطرق ‪ :‬تم اختيار خمسة آالف من المتبرعين بالدم الذين حضروا بنك الدم المركزي في محافظة السليمانية عشوائيا‬
‫واختبارها ل‪ ABO‬و‪ Rh‬ومولدات المضادات (‪ ،E ،C ،C ،D‬وه) باستخدام طريقة األنبوب‪ .‬وقد تم اختيار ‪ 533‬عينة من‬
‫األخرى‪.‬‬
‫الدم‬
‫فصيلة‬
‫أنظمة‬
‫باستخدام‬
‫تحليلها‬
‫وكذلك‬
‫عشوائي‬
‫بشكل‬
‫المتبرعين‬
‫النتائج‪ :‬في نظام ‪ ،ABO‬كان النمط الظاهري األكثر شيوعاهو ‪ ،٪(37( O‬تليها ِ‪ ، )٪02.6( A‬و‪ ))B ٪22.8‬و ‪AB‬‬
‫‪ . )٪(7.6‬بين المستضدات فصيلة الدم ‪ ،Rh‬كان ‪ e‬األكثر شيوعا (‪ ،)٪25.2‬يليه ‪،)٪62.4(c ،) C ٪ (74.8،)٪(91.3 D‬‬
‫و‪ ))E ٪30.6‬مع ‪ )DCe / DCe (R1R1‬و ‪ )rr( dce / dce‬هي الظواهر األكثر شيوعا بين ‪RhD‬االيجابي والسلبي على‬
‫التوالي‪ .‬وكانت الظواهر األكثر شيوعا ألنظمة الدم األخرى على النحو التالي‪:‬‬
‫‪Kell (K-k+,94%), Kidd (jk a+b+,44.5%), Duffy (fy a+b+,45%), Lutheran (Lu a-b+,92%), Lewis‬‬
‫‪(Le‬‬
‫‪a-b+,54.5%),‬‬
‫‪P‬‬
‫‪(P1,76%),‬‬
‫‪MNS‬‬
‫)‪(M+N+S-s+,40%‬‬
‫الخالصة‪ :‬مختلف مستضدات الخاليا الحمراء التي سجلتها أنظمة فصيلة الدم مختلفة في هذه الدراسة كان وسطا بين الدول‬
‫األوروبية واآلسيوية مع بعض الخصوصية للسكان األكراد يعكس منطقة جغرافية متميزة والخلفية العرقية المحفاظ عليها‪.‬‬
‫كلمات البحث ‪ :‬األكراد ‪ ، ABO ,‬مستضد الخاليا الحمراء ‪Rh,‬‬
‫‪80‬‬
Original article
Review of Congenital Factor XIII Deficiency in Single Iraqi Teaching
Hospital
Lubna Foad Hussain1 , Obeida Amir Abid 2
1 C.A.B.P.(ped) / Specialist Pediatrician,/ Children Welfare Teaching Hospital, Medical City,
2 F.I.B.M.S(Ped) / Specialist Pediatrician, /Children Welfare Teaching Hospital, Medical City,
Received 10/1/2016
revised 24/1/2016
accepted 6/2/2016
Abstract
Background: Factor XIII deficiency is one of the rarest bleeding disorders with an estimated
prevalence of 1in 3 million populations worldwide. The main clinical manifestations of the
disease are delayed wound healing, recurrent miscarriage, intracranial bleeding, and
prolonged umbilical cord bleeding.
Objectives: The aim of this study was to assess the diagnosis and treatment of factor XIII
deficiency in Children Welfare teaching hospital in Baghdad.
Patients and Methods: This retrospective study was performed on thirty three patients with
the severe factor XIII deficiency. The diagnosis of the disease was done by a wide spectrum
of characteristics which is part of inclusion criteria and including family history, clinical
manifestations, laboratory tests, clot solubility in 5 M urea or monochloroacetic acid
environments.
Results: the common manifestations of the disease at time of diagnosis were bleeding after
trauma (42.4%), umbilical cord bleeding (21.2%)and less frequently gum bleeding and
ecchymosis.
Conclusions: factor XIII deficiency is a rare disease in Iraq, most patients are diagnosed at
the age of 1-10 years, family history was positive in more than half of the patients.
Keywords: congenital Factor XIII deficiency, clot solubility test.
81
Review of Congenital Factor XIII Deficiency
Introduction
Congenital
factor
deficiency
is
a
XIII
rare
(FXIII)
autosomal
platelets count and bleeding time (BT)
(9)
.Diagnosis of the disease based on
recessive disease usually associated
solubility of blood clot in solution of 5
with a severe bleeding diathesis (1). The
M urea or 2% acetic acid (or1%
mortality and morbidity are primarily
monochloroacetic acid). These tests are
related
intracranial
qualitative tests and show positive
hemorrhage can be life threatening.
result if the activity of FXIII in plasma
Because the clinical bleeding is severe
of the patients is absent or close to
in most patients with hereditary factor
zero. If the results of test become
XIII deficiency, the diagnosis is made
positive
at an early age, often during infancy.
analysis of FXIII activity is needed (10).
to
bleeding;
Bleeding from the stump of the
umbilical cord within the first days to
weeks of life is a characteristic sign
that
occurs
individuals
in 80%
(2,3)
of affected
. Additional signs of
bleeding include the following: CNS
hemorrhage is frequent (25-30%) and
may occur spontaneously or after
minor trauma
(4-7)
. Soft tissue bleeding
and bruising are very common
(4,5)
.
Hemarthroses occur in 20% of cases
.Bleeding that is delayed (ie:12-36h)
after trauma or surgery is diagnostic of
factor XIII deficiency.(8)
by
observing
quantitative
Replacement therapy in this deficiency
can be administered through fresh
frozen
plasma
inactivated),
(preferably
cryoprecipitate
virusand
pasteurized FXIII concentrates. The
first FXIII from human source that
used in replacement therapy was
produced from placenta but later this
product replaced by plasma extracted
FXIII concentrates
(5,11-13)
.The aim of
the study is to assess the diagnosis and
treatment of factor XIII deficiency in
Children Welfare Teaching Hospital,
Medical City, Baghdad.
FXIII deficiency can be initially
diagnosed
subsequent
Patients and methods
bleeding
episode with normal routine clotting
tests including prothrombin time (PT),
activated partial thromboplastin time
(aPTT), fibrinogen level,
It is a retrospective study. The study
participants included all patients age
group who were attend the hemophilia
center in Children Welfare Teaching
82
Hospital with the diagnosis of FXIII
deficiency, from
January 2 000 till
April 2015. All patients were identified
by using coded discharge records with
the diagnosis of factor XIII deficiency.
Data collected included: Gender, age at
presentation,
presenting
complaint,
family history, type of treatment (fresh
frozen
plasma,
cryoprecipitate),
hepatitis B ,C in patients.
Results
Thirty three patients were diagnosed to
have factor XIII deficiency. 20(58%)
were males shown in Figure (1). The
diagnosis of
FXIII deficiency was
established at 3 age groups; first group
less than 1 year, second group 1-10
years and third group more than 10
years; most patients diagnosed at the
age of 1-0 years as shown in Figure (2)
The following investigations were
Post traumatic bruises were the major
reviewed for all patients who presented
presenting complaint in 14 patients
to the outpatient clinic to establish the
(42.4%) , followed by prolonged
diagnosis and included complete blood
bleeding from umbilical stump in 7
picture and coagulation screen PT
patients(21.2%).
,APTT and
intracranial hemorrhage diagnosed by
bleeding time which
reported to be normal.
Diagnosis
was
confirmed
by
mol/L urea which was done to all our
patients, a qualitative test for diagnosis
FXIII deficiency; those found
positive were labelled as factor XIII
deficient.Results were expressed as
frequencies
and
patient
had
neuro-imagining study .Table1
performing clot solubility tests in 5
of
One
percentages
and
presented in tables and figures using
Microsoft Office Excel 2013.
Family history was positive in 20
patients (58%).
The products used in the treatment of
these patients only when presented
with bleeding included fresh frozen
plasma, cryoprecipitate. Testing for
transmission of viral infections was
also done in all our patients and only 2
from 6 patients received plasma were
found with hepatitis C positive after
repeated transfusions of fresh frozen
plasma.
83
The other 27 patients were treated by
infection .Hepatitis B was found
cryoprecipitate with no hepatitis C
negative
in all patients .Figure3
Gender of the patients
42%
Male
58%
Female
Figure1:The gender of 33 patients
Table1:The presenting complaints at the time of the diagnosis of 33 patients
Bleeding type
Frequency(no.)
Percent(%)
Post traumic bruises
14
42.4
Umbilical cord bleeding
7
21.2
Gum bleeding
5
15.2
After circumcision
2
10% of males
Muscle hematoma
2
6.1
Ecchymosis
1
3.0
Epistaxis
1
3.0
Intracranial hemorrhage
1
3.0
Total
33
84
17
11
5
LESS 1 YEARS
1-10 YEARS
MORE TEN YEARS
Figure2:The age of diagnosis in 33 patients
6%
negative
94%
positive
Figure3:The results of Hepatitis C screening
85
Discussion
This disorder is so rare that to date
of the patients presented early in their
only 33 of 778 patients with congenital
life, which is supported by this study
bleeding
which is the same in Iranian, Saudis
disorders,
have
been
identified in our hemophilia center
with factor XIII deficiency. So the
incidence of this disorder is 0.042%. In
Saudia Arabia it is also a rare disease
(14)
.While in Pakistan it was the fifth
most
common
factor
deficiency
detected in one study conducted there
(15)
. In Iran, a Middle Eastern country
with a high rate of consanguineous
and Pakistani study.(14-16)
In this study family history is positive
in 94% of patients due to higher
incidence of interfamilial marriages. In
Iranian and Saudi study (59%) had a
family history of FXIII deficiency
(14,16)
.In
Pakisatan
positive
family
history was present in 42.4% of
patients.(15)
marriages, there are approximately 473
FXIII
In Iraq FXIII concentrate is not
deficiency. An approximately 12-fold
available till now, in Pakistan all
higher prevalence of FXIII deficiency
patients treated with fresh frozen
is estimated in Iran in comparison with
plasma and cryoprecipitate
patients
afflicted
with
overall worldwide frequency.
(14)
.
In this study, bleeding after trauma is
the most common, while in Iranian and
(15)
and the
same applied for Iran until 2009 when
FXIII concentrate became available for
patient management. (14)
Pakistani study showing subcutaneous
The challenges that we faced in the
bleeding (57%), followed by umbilical
diagnosis was the unavailability of
cord
muscle
quantitative assay and in the treatment
intracranial
was the unavailability of plasma
bleeding
hematoma
(56%),
(49%)
and
hemorrhage (34%) to be the major
clinical presentation
(14,15)
derived FXIII product.
. In Saudis
the presenting symptoms included
ecchymosis in 12 patients (71%),
bleeding after circumcision in 6 male
patients
(55%),
umbilical
stump
bleeding in 7 (41%), and intracranial
bleeding in 3 patients (18%) (16). Most
86
Conclusion
3. Siboni S, Zanon E, Sottilotta G, et
Factor XIII deficiency is a rare disease
in Iraq with low incidence, most
patients diagnosed at the age of 1-10
al. Central nervous system bleeding in
patients with rare bleeding disorders.
Haemophilia. 2012;18(1):34–8.
years, family history was positive in
4. Karimi M, Bereczky Z, Cohan N,
more than half of the patients.Thus in
editors Factor XIIID. Seminars in
children
thrombosis
traumatic
umbilical
with history of
bruising,
bleeding
post
prolonged
along with any
family history of easy bruising
and
consanguinity in parents, it is essential
to rule out FXIII deficiency especially
in those with normal
and
hemostasis.2009 Jun;35(4):426-38.
5. Eshghi P, Cohan N, Naderi M, et al.
Factor XIII deficiency: a review of
literature Iranian Journal of Blood and
Cancer. 2010;4: 85–91.
6. Sawlani KK, Chaudhary SC, Roy A,
Author contributions:
et al. Factor XIII deficiency presenting
Dr.Lubna Foad Hussain: Acquisition
with intracerebral bleed. BMJ Case
of data analysis , interpretation of data
Rep. ;Epub 2013/01/15.
, critical revision.
Dr. Obeida Amir
7. Naderi M, Dorgalaleh A, Alizadeh
Abid : Study
S,
et
al.
Polymorphism
conception, study design, drafting of
thrombin‐activatable
manuscript, and Coagulation studies.
inhibitor
and
risk
of
fibrinolysis
of
intracranial
haemorrhage in factor XIII deficiency.
Haemophilia. 2014 Jan;20(1):e89-92.
References
8. Helge Dirk Hartung, MD; Chief
1.
Bolton-Maggs
PH.
The
rare
Editor: Max J Coppes, MD, PhD,
inherited coagulation disorders. Pediatr
MBA.Pediatric Factor XIII Deficiency
Blood Cancer. 2012: S37.
Clinical Presentation. Medscape.
2. Naderi M, Imani M, Eshghi P, et al.
9. Kessel R, Hu C, Shore-Lesserson L,
Factor XIII deficiency in Sistan and
et al. A child with acquired factor XIII
Baluchistan province. Sci J Blood
deficiency case report and literature
Transfus Organ. 2013;10(3):282–8
review. 2013 Nov;19(6):814-26.
87
10. Bay A, Sirikci A, Dogan A,
16. Al-Sharif FZ1, Aljurf MD, Al-
Leblebisatan G, et al. Spontaneous
Momen
Acute Cerebral Hematoma in a Child
laboratory features of congenital factor
with Factor XIII Deficiency. Pediatr
XIII deficiency.Saudi Med J. 2002
Hematol Oncol. 2013.
May;23(5):552-4.
AM,
et
al.Clinical
and
11. Opat S, Butler J, Malan E, et al.
Factor XIII assays. Methods Mol Biol.
2013;992:171–80.
12. Williams M, Will A, Stenmo C, et
al. Pharmacokinetics of recombinant
Correspondence to:
Dr. Obeida Amir Abid
Dept. of hemophilia
factor XIII in young children with
Children welfare hospital
congenital
Medical city
FXIII
comparison
deficiency
with
older
and
patients.
Haemophilia. 2013.
13.
Caudill
e-mail: [email protected]
Mobile; 07727825155
JSC,
Nichols
WL,
Plumhoff EA, et al. Comparison of
coagulation factor XIII content and
concentration in cryoprecipitate and
fresh‐frozen
plasma
Transfusion.
2009:49(4):765_70.
14. Dorgalaleh A, Naderi M, Hosseini
MS, et al.Factor XIII deficiency in
Iran: a comprehensive review of the
literature.Semin
Thromb
Hemost
. 2015 Apr;41(3):323-9.
15. Anwar M, Iqbal M, Ayyub M ,et
al. Prevalence of factor XIII deficiency
in patients presenting with a bleeding
disorder
published
in
Pakistan.Article
online:
first
DOI:
10.1111/j.1538-7836.2003.0543j.
88
‫‪Lubna Foad Hussain, Obeida Amir Abid‬‬
‫‪Review of Congenital Factor XIII Deficiency‬‬
‫نقض انعامم انوراثي انثانث عشر في احذى مستشفيات انعراق انتعهيميو ‪/‬دراسو وطفيو‬
‫د‪.‬نبني فؤاد حسين‪ 1‬د‪.‬عبيذه عامر عبذ‪2‬‬
‫‪ 1,2‬طبيب اختظاص في طب االطفال‪ /‬مستشفي حماية االطفال انتعهيمي‪ /‬مذينة انطب‬
‫انخالطو‪:‬‬
‫خهفية انبحث‪َ :‬قص عبيم انحخرش انربند عششانٕساذً ْٕ يٍ االظطشاببت انُضفٍّ انُبدسِ انحً جحذخ فً انبشش‪,‬‬
‫جقذس َسبة حذٔذّ بُسبة ‪ 1‬نكم ‪ 3‬يهٌٍٕ يٍ عبية انُبط‪.‬يٍ اْى عاليبت انًشض جأخش انحئبو انجشٔح‪ ,‬اسقبطبت‬
‫يحكشسِ عُذ انحٕايم‪َ ,‬ضف يطٕل يٍ يكبٌ انحبم انسشي عُذ حذٌرً انٕالدِ‪.‬‬
‫االىذاف ‪ :‬جٓذف ْزِ انذساسّ انى جحذٌذ عٕايم انحشخٍص ٔانعالز نُقص عبيم انحخرش انربند عشش انُضفً‬
‫انٕساذً فً يسحشفى حًبٌة االطفبل انحعهًًٍ فً بغذاد‪.‬‬
‫انمواد وانطرق‪ :‬دساسّ يسحشدِ ٔٔصفٍّ ل‪ 33‬يشٌط يشخصٍٍ بُقص عبيم انحخرشانربند عشش انٕساذً‬
‫اجشٌث بٍٍ االٔل يٍ جًٕص‪ 0222‬انى االٔل يٍ ابشٌم ‪ .0212‬جى انحشخٍص ببالعحًبد عهى انحبسٌخ انعبئهً‬
‫ٔانعاليبت انسشٌشٌّ ٔانفحٕصبت انًخحبشٌّ‪.‬‬
‫اننتائح‪ :‬اكرش انعاليبت انًشظٍّ شٍٕعب عُذ انًشظى اذُبء انحشخٍص كبَث انُضف بعذ حذٔخ االصبببت‬
‫‪,‬انُضف يٍ يكبٌ انحبم انسشي عُذ حذبرً انٕالدِ‪َ ,‬ضف انهرّ ذى ظٕٓس بقع َضفٍّ جحث انجهذ‪.‬‬
‫االستنتاج‪ :‬جظٓش ْزِ انذساسّ اٌ َقص عبيم انحخرش انربند عشش انٕساذً ْٕ يٍ االيشاض انُبدسِ فً انعشاق‬
‫‪.‬اكرش االعًبس انحً ٌحى فٍٓب جشخٍص انًشض ‪ 12- 1‬سُٕات‪ .‬جبسٌخ انعبئهّ كبٌ يٕجبب فً اكرش يٍ َصف‬
‫انحبالت انًشظٍّ ‪.‬‬
‫انكهمات انرئيسية‪َ :‬قص عبيم انحخرش انربند عشش انٕساذً‪َ ,‬ضف يطٕل يٍ يكبٌ انحبم انسشي‪ ,‬اخحببس رٔببٌ‬
‫انجهطّ‪.‬‬
‫‪89‬‬
Original article
CD38 and ZAP-70 as prognostic immunological parameters in patients
with chronic lymphocytic leukemia
Intisar Sh. Ali 1 ,Ghassan A. Al-Anni 2 , Salman A. Al-Jubury 3
1 M.Sc. microbiology/laboratory dept./ Alyarmouk teaching hospital
2 consultant Hematopathologist/ FICMS hematopathology/ head of Lab. dept. /Alyarmouk teaching
hospital
3 Prof. Of clinical immunology/ microbiology dept./university of kufa college of medicine
Received: 15/1/ 2016
Accepted: 17/ 2/ 2016
Abstract
Background: Several immunological parameters have been investigated in patients with chronic
lymphocytic leukemia (CLL). Some of them are important in detecting the prognosis of the
disease.
Objectives: the aim of this study was to evaluate the level of ZAP-70 and CD38 in patients with
newly diagnosed chronic lymphocytic leukemia.
Materials and methods: The study was done on 50 patients with newly diagnosis CLL 36 male
and 14 female. CD38 and ZAP-70 were measured in patients by using flow cytometry. These
patients were divided according to Ria stage into 29 patients with group II, 21 patients with group
I, group I included Rai stage O, I, II in which the RBC and platelet counts are normal while group
II included Rai stage III and IV in which RBC and platelet count are low.
Results: ZAP-70 and CD38 were significantly increased in patients with group II when compared
to group I. ZAP-70 and CD38 may be regarded as bad prognosis factor for CLL patients.
Conclusion: From the results of the current study, we conclude that ZAP-70 and CD38
high level in patients with chronic lymphocytic leukemia is associated with bad prognosis
Keywords: CD38, ZAP-70, CLL
90
CD38 and ZAP-70 as prognostic immunological
Intisar Sh.Ali,,Ghassan A.Al-Ani, Salman A.
Introduction
Chronic lymphocytic leukemia is the
The expression of ZAP-70 (˃ or = 20%
most common lymphoid malignancy, it
of B cell) has showed to associated with
is a disease predominantly seen in
increased risk for bad prognosis in
elderly with the incidence twice higher
patients with CLL and is regarded as
men
(1)
. CLL showed familial tendency
with 3-8 times higher than in normal
population
(2)
.Chronic
lymphocytic
leukemia characterized by accumulation
of terminally different clonal of CD5+
B-cell
from
proliferation
and
differentiation in the bone marrow and
secondary lymphoid organ. It is the most
common type of malignancy in the
western world but its incidence is low in
Far
East
(3)
.
Chronic
lymphocytic
leukemia has different prognosis where
the disease may be growing slowly with
minimal changes in blood cell count;
other may have a faster growing
malignancy (4).
great risk factor in those patients (6).
CD38
is
glycoprotein
with
small
cytoplasmic region (21 amino acids), a
single chain transmembrane region (23
amino acids), and 256 amino acid
extracellular domain that can be loosely
divided
into
two
regions.
The
extracellular amine protein consists of
156 amino acids that make up 5 αhelices. This region is adjacent to the
COOH domain (amino acids 200-300)
that contains four parallel P-sheets
surrounded by two long and two short α(7)
helices
.CD38 expression on the
leukemic cell regarded as an excellent
prognostic
indicator
because
it's
ZAP-70 is a member of the tyrosine
measured from peripheral blood sample
kinase group of protein and is normally
easily
showed in T-cell and natural killer cells
CD38
(NK). ZAP-70 have a vital role in the
identification of sub group of patients
regulation of normal T-cell functions,
with
such as T-cell receptor(TCR),signal
presumably poor prognostic and the
initiation,
detection of patients with poor prognosis
T-cell
activation,
cell
migration and apoptosis (5).
(8)
among
. Furthermore, measurement of
expression
better
what
arrows
prognosis
is
the
within
considered
a
better
prognostic group (9).
91
Materials and methods:
This study was done of 50 patients with
evaluate differences between the studied
newly diagnosed chronic lymphocytic
groups.
leukemia from March 2013 till March
considered
2015 included 36 male and 14 female,
Analysis of data was carried out using
the age of the patients rage from 45-75
the available statistical package of SPSS-
years, all of the patients were diagnosed
22 (Statistical Packages for Social
morphologically as chronic lymphocytic
Sciences-version 22).
leukemia. These patients were attending
Medical City in Baghdad, National
For
all
test,
statistically
P≤0.05
was
significant.
Results :
Center of Haematology (University of
Table (1) and figure (1) represent the
Mustansyria),
Teaching
comparison of the mean value of ZAP-
Hospital and Al-Emammain kadhumain
70 in patients of group I and group II
Medical City.
chronic lymphocytic leukemia.
Those patients were divided into two
The ZAP-70 level in patients with group
groups according to Rai staging group I
II chronic lymphocytic leukemia was
included Rai stage O, I, II in which the
significantly increased (p=0.0001) when
RBC and platelet counts are normal
compared to group I.
Al-Yarmouk
while group II included Rai stage III and
IV in which RBC and platelet count are
low. ZAP-70 and CD38 were determined
in patients of the above group by flow
Table (2) and Figure (2) represents the
comparison of the mean value of CD38
concentration in the sera of group I and
group II chronic lymphocytic leukemia.
cytometry method using Four-Colour
CD38 value were significantly increased
Cyflow®
(p=0.001) in patients with group II
Statistical
analysis:Data
were
expressed; Student's t-test was used to
chronic lymphocytic leukemia when
compared to group I.
92
Table (1): levels of ZAP-70 in group I and II chronic lymphocytic leukemia
ZAP-70
Group I (n=21)
Group II (n=29)
Mean ± SD
8.82±17.10
37.58±22.29
Standard Error of Mean
3.73
4.14
Range
0.19-61.97
1.22-87.04
50th (Median)
0.90
24.49
P value
0.0001*
*Significant difference means using Student-t-test for difference between two independent
means at 0.05 level.
Table (2): level of CD38 in patients with CLL group I and II
CD38
Group I (n=21)
Group II (n=29)
Mean ± SD
6.25±9.30
36.01±24.60
Standard Error of Mean
2.03
0.574
Range
0.53-39.28
0.96-78.92
50th (Median)
2.49
28.64
P value
0.0001*
*Significant difference means using Student-t-test for difference between two independent
means at 0.05 level.
93
Figure (1): Distribution of ZAP-70 (mean±SD) in patients with chronic lymphocytic
leukemia group I and II
Figure (2): Distribution of CD38 (mean ± SD) in patients with chronic lymphocytic
leukemia group I and II
94
Discussion
There
are
immunological
Regarding CD38, the data in this study
determine
the
showed that it might be useful for
prognosis at the time of diagnosis of
prognosis of the disease since the value
CLL that would help the decision about
of CD38 increase as the disease progress
treatment and to determine the outcome
and patients with CD38 high value may
parameters
many
used
of the disease
(10)
to
.ZAP-70 is a member of
be regarded bad prognosis for the
the family of intracellular tyrosine
patients
kinases, is significantly expressed in
leukemia
normal T cells. It is also may be express
with previous results which indicate that
at early stage of chronic lymphocytic
expression of CD38 patients with CLL is
leukemia
(11)
. The result in the present
study determine that ZAP-70 might be
useful for detecting the prognosis of the
disease because the level of ZAP-70
in
(13)
chronic
lymphocytic
.This observation agreed
associated with bad prognosis and poor
outcome (14).
Conclusion
increase in patients with group II chronic
From the results of the current study, we
lymphocytic leukemia when compared
conclude that ZAP-70 and CD38 high
to group I chronic lymphocytic leukemia
level
patients. The data in our study regarding
lymphocytic leukemia is associated with
ZAP-70 value agreed with previous
bad prognosis.
result which indicate that ZAP-70 in
patients
with
chronic
in
patients
with
chronic
References
lymphocytic
leukemia increase as the disease progress
1. Bain B., and Barbara J. Leukaemia
(12)
diagnosis 4th ed.;2010 . p65-74.
. CD38 is a protein that have many
function belongs to the number of
molecules
independently
as
ecto-enzymes as receptors, CD38 may
split
the
patients
with
chronic
lymphocytic leukemia into two groups
and represent a dependable negative
prognostic factor (13)
2.
Arena
G.,
Keating
Carotenuto
C.
lymphoproliferative
integrated
differential
M.L.
point
of
and
Chronic
disorders:
an
view
the
diagnosis.
for
Leukemia
Lymphoma 2000; 36,225–237.
95
3.
Mir
M
.Chronic
Lymphocytic
9. Liu Q., Kriksunov I., Graeff, R., and
Leukemia. Medscape 2013; 4:1993-
et al.Crystal structure of human CD38
1994.
extracellular domain. Structure 2005; 13:
4. Elter T., Hallek M., Engert A.
Fludarabine
in chronic
1331-1339.
lymphocytic
10. Digheiro G.,and Hamblia T.Chronic
leukemia, Export Opin Pharmacother
lymphocytic leukemia. Lancet 2008;
2006; 7(12):1641-1651.
371(9617): 1017-1029.
5. Chen L., Widhopf G., Huynh L., and
11. Nagwa M.,Kathyrn R.,Felisa Al
et al. Expression of ZAP 70 is associated
concia, and et al. A single tube, four
with increased B cell receptor signaling
color
in chronic lymphocytic leukemia. Blood
evaluation
2002; 100: 4609-14.
expression CLL. American Journal of
6. Gobossi S., Laurenti L., Longo P.G.,
flow
cytometry
of
ZAP-70
assay
and
for
CD38
clinical pathology 2010; 133:708-717.
and et al. ZAP-70 enhances B cell
12. Maria Ilaria. .Del principle,American
receptor signaling despite absent or
society of haematology 2006;108(3).
inefficient tyrosine kinase activation in
chronic
lymphocytic
leukemia
and
lymphoma B cell. Blood 2007;109:20322039.
al.
ZAP-70
expression
chronic
lymphocytic leukemia and inhibit B cell
receptor
ZAP-70 expression is a prognostic factor
in
chronic
lymphocytic
leukemia.
Leukemia 2003;17:2426-34.
7. Deïlschneidr R., Xiao V., Yoon J., and
et
13. Dürig J., Nuckel H., Cremer M. et al.
signaling.
Cell
14. Sylvan S.Targeted therapy and
outcome
in
chronic
lymphocytic
leukemia. Ph.D. thesis.2014
death and
disease 2014; 5:439-442.
8. Malavasi F., Deaglio S., Funaro A.,
and et al.Evolution and function of the
Correspondence to:
Intisar Sh. Ali MSc. Dept. of
micerbilogy/ Alyarmouk teaching Lab.
ADP ribosyl cyclase / CD38gene family
in physiology and pathology. Physiol
Rev 2008; 88: 841-886.
e-mail:[email protected]
mobile: 07735674539
96
‫‪Intisar Sh.Ali,,Ghassan A.Al-Ani, Salman A.‬‬
‫‪CD38 and ZAP-70 as prognostic immunological‬‬
‫‪ CD38‬و‪ 07-ZAP‬معلمات مناعية للتكهن في المرضى الذين يعانون من سرطان الدم الليمفاوي‬
‫المزمن‬
‫انتصار علي ‪ ،1‬غسان احمد خليل العاني ‪ ،2‬سلمان الجبوري ‪3‬‬
‫‪ 1‬ماجستير علم األحياء الدقيقة ‪ /‬قسم المختبرات ‪ /‬مستشفى اليرموك التعليمي‬
‫‪ 2‬استشاري امراض الدم المختبري ‪ / FICMS /‬رئيس قسم المختبرات ‪ /‬مستشفى اليرموك التعليمي‬
‫‪ 3‬أستاذ المناعة السريرية ‪ /‬قسم االحياء المجهرية ‪ /‬كلية الطب الكوفة‬
‫الملخص‬
‫الخلفية ‪ :‬هناك عدة انواع من المعلمات المناعيه نم دراستها في مرضى ابيضاض الدم اللمفاوي المزمن ‪.‬بعض من هذه‬
‫المعلمات مهمه في تعيين حالة المريض ‪.‬‬
‫االهداف ‪:‬اجريت هذه الدراسه لمعرفة فائدة ‪ ZAP-70‬و ‪ CD38‬في مرضى ابيضاض الدم اللمفاوي المشخصين حديثا‪.‬‬
‫المواد والطرق ‪ :‬تم اجراء هذا البحث على ‪ 07‬مريضا ‪ 33‬ذكور و‪ 14‬اناث‪ ،‬حيث تم قياس ‪ ZAP-70‬و ‪ CD38‬في‬
‫مصول هؤالء المرضى بواسطة جهاز الفلوسايتومتري‪ .‬تم تقسيم هؤالء المرضى الى قسمين المجموعه االولى تضم‬
‫(‪ )21‬مريض والثانيه تضم (‪ )22‬مريض‪.‬‬
‫النتائج ‪ :‬لقد كانت هناك زياده محسوسه في مستوى ‪ ZAP-70‬و ‪ CD38‬في مصول مرضى المجموعه الثانيه مقارنه‬
‫بالمجموعه االولى وبذلك بين اهميه ال ‪ ZAP-70‬و ‪ CD38‬كمعلمات لسؤء حالة المريض المصاب بابيضاض الدم‬
‫اللمفاوي‪.‬‬
‫االستنتاج ‪ :‬من نتائج الدراسة الحالية‪ ،‬فإننا نستنتج أن هناك ارتباط بين ‪ ZAP-70‬و ‪ CD38‬على مستوى عال في‬
‫المرضى الذين يعانون من سرطان الدم الليمفاوي المزمن مع المسيرة السيئة لهذا المرض‪.‬‬
‫الكلمات الرئيسية‪ ZAP-70 :‬و‪ , CD38‬سرطان الدم الليمفاوي المزمن‬
‫‪97‬‬
Original article
Evaluation the Role of Bone Marrow Examination in Diagnosis of
Hematological Diseases in Hemato-Oncology Centers in Kurdistan
Region
1
Shorsh Jameel Ridha , Nawsherwan Sadiq Mohammad 2,
Hoger Ismael Muhammed Sarhang3
1 MBChB-MSc Hematology /Hiwa Teaching Hospital
2 MBChB- FICMS Hematology/Pathology Department; College of Medicine / Hawler Medical University
Email: [email protected]
Mob: 00964(0)7504384101
3 MBChB-MSc Hematology/ Erbil Teaching Hospital
Received:
10/2/2016
accepted: 13/3/2016
Abstract
Background: Bone marrow aspiration and trephine biopsy have an important role in evaluation
and diagnosis of most hematological and some non hematological disorders.
Objectives: The aims of this study were to assess the value of bone marrow examination in
diagnosis of hematological diseases and determination of frequency and causes of dry tap
marrow.
Patients and Methods: This study was prospective only and it was conducted from January 2013
to June 2013 at Hiwa and Nanakaly hospitals in Sulaymaniyah and Erbil respectively. A total
number of 245 cases were underwent bone marrow examination. Touch imprint was prepared in a
state of dry tap marrow. Sudan black stain was used in acute leukemia.
Results: The patients comprised 138 (56.3%) males and 107 (43.7%) females, with ages ranging
from 1 to 81 years and the mean age of cases was 36.7± 24 years. The most frequent clinical
finding of patients underwent bone marrow examination were pallor (71.4%), followed by fever
(32.2%). The main indications were present of blast cells in peripheral circulation 69 (28.2%),
followed by bone marrow assessment for staging of lymphoma 37 (15.1 %). The most common
diagnoses encountered were: Acute leukemia 69 (28.2%), Active marrow (negative for
lymphoma) 27 (11.1%) and active marrow 24 (9.8%). The frequency of dry tap was (4.08%) and
the most common causes were: acute leukemia and faulty technique (normal marrow).
Conclusion: Bone marrow examination is an important diagnostic tool in the diagnosis and
staging of various hematological disorders.
Keywords: Bone Marrow Aspiration, Trephine Biopsy, Hematology, Kurdistan
98
Evaluation the Role of Bone Marrow Examination
Shorsh J. R, Nawsherwan S.M, Hoger I.M.S.
Introduction
Bone marrow is a quite cellular
marrow examination, there are some
connective tissue that occupying the
contraindications which are related to
spaces between bony trabeculae. The
the general condition of the patient.
main hemopoietic tissue is bone marrow
These contraindications are hemophilia,
and it accounts for about (5%) of all
disseminated intravascular coagulation,
body weight. Bone marrow aspiration
skin infection and bone disorders such as
and trephine biopsy have an important
osteomyelitis
role in evaluation and diagnosis of most
imperfecta (4,5).
hematological
and
osteogenesis
non
Both procedures are usually safe
hematological disorders. Bone marrow
but few adverse effects are encountered
examination is needed for staging of
after bone marrow examination. The
lymphoproliferative
In
popular complication is bleeding which
advanced stage, it shows bone marrow
occurs specially in patients with severe
involvement. Also trephine biopsy is
low platelet count, or taking aspirin, or
more important than marrow aspiration
receiving anticoagulant
in
and
Other morbidity from posterior iliac
These
crest are identified and included long
procedures are valuable in the diagnostic
standing pain, infection in immune
work up of pyrexia of unknown origin; it
compromised patients and needle-related
may
accidents such as breaking of needle
evaluation
metastatic
shows
of
solid
some
or
disorders.
lymphoma
tumors.
granuloma,
infection,
necrosis and hemophagocytic syndrome.
as warfarin.
within the bone (6,7).
They are useful in follow up evaluation
In some certain situation, failure
of patients who submit chemotherapy,
to take out bone marrow on trying
bone marrow transplantation and other
marrow aspiration, known as dry tap or
patterns of medical management(1,2,3).
blood tap and these are generally
Bone marrow aspiration and
described as faulty technique. This
biopsy procedures are complementary to
difficulty of aspiration may be occurred
each other and superiority of one
when histology of marrow is normal.
procedure over the other relied on the
But usually a dry tap indicates important
particular disorders (1). In obtaining bone
disorders that involve bone marrow. The
99
most prominent pathological disorders
and routine investigations (complete
are metastatic carcinoma, myelofibrosis,
blood count, pictures, and erythrocytes
acute leukemia (packed cells), hairy cells
sedimentation rate
leukemia and lymphoma. In Dry tap
tests) were carried out prior to bone
status, touch imprint must be prepared
marrow
examination.
for early prime diagnosis before the
technique
(4)
result of trephine biopsy was returned
the samples from posterior iliac crest by
back
(8,9)
and
biochemical
The
standard
was employed in obtaining
. In this study we tried to assess
using a biopsy set needle (Modern bone
the value of bone marrow examination in
marrow biopsy needle set /11 gauge/
diagnosis of hematological diseases and
Italian). About 0.5 ml of marrow fluid
to determine the frequency and causes of
was obtained and nearly about ten
dry tap marrow.
smears prepared. Two slides were
stained with Prussian blue technique by
well trained staff to demonstrate iron
This prospective study has been
conducted
at
Hiwa
and
granule and ring sideroblasts when
Nanakaly
indicated. Sudan Black stain was used
hospitals which are only centers for
routinely for all patients with acute
oncology/hematology in Sulaymaniyah
leukemia.
and Erbil respectively. All patients
When biopsy was performed, the
underwent bone marrow examination
core biopsy was fixed in formalin and
between January 2013 and June 2013,
sent for processing in histopathology
were enrolled in this study. Relapsed and
department (Rizgary Teaching Hospital
follow-up cases were excluded. A total
in
number of 245 cases were studied. One
Sulaymaniyah) and was examined by 2
hundred
pathologists
case
was
received
from
Erbil
and
Shorsh
hospital
independently.
in
Touch
Nanakaly hospital and 145 cases were
imprint smears were usually made in
collected from Hiwa hospital.
cases with dry tap aspiration.
Inform consent was taken from
For
some
patients
with
patient and their relative (In childhood
lymphoproliferative disorders and acute
cases). In each case a detailed history
leukemia,
with general and systemic examination
collected in Ethylene diamine tetra
marrow
materials
was
100
acetic acid tube and sent for flow
0.05
was
cytometry analysis. Also some patients
significant.
considered
statistical
with chronic myeloid leukemia and
myeloproliferative neoplasm in whom
Results
the diagnosis were not straight forward,
A total of 245 cases underwent
specimens were sent for BCR- ABL
bone marrow examination from January
fusion
2013 to June 2013 were included in this
gene
and
JAK2
mutation
respectively.
study. Males were 138 (56.3%) and
The marrow was examined and
females were 107 (43.7%). The ratio of
interpreted by two hematologist and was
male to female was (1.29:1). The age of
reviewed with consideration of the
patients in this project were ranged
patient’s
between 1 to 81 years with mean age of
clinical
information.
and
Marrow
laboratory
smears
are
36.71+ 24 years.
examined for determination of the
The
cellularity, the morphological details of
examination were based on the clinical
hemopoietic cells, estimation of myeloid
and or complete blood pictures. In this
– erythroid ratio and careful search for
study,
abnormal cells. A questionnaire was
examination of bone marrow were
designed that contains a set of questions
presence of blast cells in peripheral
including (residence, age, sex, clinical
circulation which was seen in 69
features, organomegaly, complete blood
(28.2%) cases, followed by bone marrow
picture, other related investigations and
assessment for staging of lymphoma in
bone marrow examination report). The
43 (17.5%) patients, and then anemia in
questionnaire
20 (8.2%) cases. Leucocytosis was
type
is
structured
interviewer administrated.
indications
the
for
main
bone
marrow
indications
for
another indication and found in 14
Data were analyzed by using the
(5.6%) cases, 12 of them showed marked
statistical package for social science
left shift with increased basophilic count
(SPSS) version 19. Chi square test of
and associated with organomegaly, these
association
compare
were diagnosed as CML. The remaining
between proportions. A P-value of ≤
two cases were leucocytosis without
was
used
to
101
shift to left, one of them was diagnosed
frequency
as active marrow and the other one
marrow examination was anemia and
regarded as
was found in 24 (9.8%) patients and the
non diagnostic.
Other
indications were explained in table 1.
of
indications
for
bone
outcome of bone marrow examination
Various hematological disorders
were active marrow in (13) cases,
were encountered in this study as the
multiple myeloma in (7) cases, pure red
result of bone marrow examination. The
cells aplasia in (2) cases and erythroid
most frequent final diagnosis was acute
hyperplasia in (2) cases. Table 3
leukemia and accounting for 69 (28.1%)
cases
of which 40
patients
Out of 245 samples 10 (4.08%)
were
cases were regarded as dry taps and
diagnosed as ALL and 29 cases were
touch imprints with trephine biopsy
categorized as AML. The next in the
material were obtained from posterior
descending order of frequency was
iliac crest for diagnosis. Of these 10
active marrow (negative for lymphoma)
cases, only 3 (30%) patients were
and found in 27 (11.1%) cases. Other
revealed active biopsy, while others
final diagnoses are illustrated in table 2.
showed significant marrow pathology.
A comparison was
prepared
Acute leukemias were the commonest
between the indication for bone marrow
pathological causes of dry taps and
examination and final diagnosis that
found in 3 (30%) cases, two of them
made after examination of the bone
were ALL and the remaining one was
marrow. Acute leukemias were found in
AML. Other causes of dry tap are clearly
69 (28.1%) cases and final diagnoses of
explained in (Fig 2).
this category were 40 cases of ALL and
In total 245 cases were underwent bone
29 cases of AML (fig 1).
marrow aspiration and trephine biopsy
Of the 37
(15.1%) patients were referred for bone
no complication were reported.
marrow examination for staging of
lymphoma, 27 cases didn't showed
marrow involvement by lymphoma and
10
cases
were
demonstrated
bone
marrow infiltration by lymphoma cells.
The next in the descending order of
102
Discussion
Both bone marrow aspiration and
causes was ranked the first frequent
trephine biopsy are essential and safe
indication due to high frequency of
procedures for diagnosis of various
nutritional anemia as iron deficiency and
hematological and non-hematological
megaloblastic anemias13. Leucocytosis
disorders. These are important for follow
was also another indication and was seen
up
received
in 14 (5.6%) patients, where it was
marrow
mostly due to CML that was found in 12
transplantation and/or other medical
cases, while the rest two cases were
treatment. Bone marrow aspiration and
regarded as active marrow and non
trephine biopsy are complementary to
diagnostic marrow.
of
patients
chemotherapy,
each
other
who
or
and
nowadays,
both
procedures are performed together and
usually on same site routinely (10).
The result of this study showed
that the acute leukemias were the most
frequently encountered diagnosis by
The most popular indication in this
bone marrow examination and these
study was presence of blast cells in
were found in 69 (28.1%) cases, 40
peripheral circulation (acute leukemia)
patients of them were ALL with mean
which were found in 69 (28.2%) cases,
age 16.8 years and 31 (77.5%) of them
followed by staging for lymphoma in
were found in 1st and 2nd decades, while
descending order of frequency and was
29 cases were AML with mean age 35
found in 37 (15.1%) cases. Similar
years and 10 of them were seen in 3rd
findings were reported by Bashawri and
and 4th decades; however references set
Al–Gwaiz as acute leukemia was the
that AML is the commonest acute
most common indication and was found
leukemia in adults and ALL is the
in
cases
commonest childhood malignancy (14). A
. In contrast to these
similar study was done by Gupta et al
findings, acute leukemia was ranked
and Egesie et al in India and Niger
fourth common indication (1.25%) in a
respectively, in which acute leukemias
study done by Bedu-Addo et al in
were the largest group disorders
Ghana, in which anemia of unknown
Acute leukemia was ranked third in a
(32.9%)
respectively
and
(11,12)
(26.2%)
(15,16)
.
103
study done by Pudasaini et al from
even in cases with bicytopenia and mild
Nepal, in which frequency of erythroid
anemia (2).
hyperplasia
(mostly
due
to
iron
deficiency and megaloblastic anemia)
were high and these were due to higher
prevalence of nutritional deficiency in
their locality (17).
indication for bone marrow examination
was staging of lymphoma and found in
37 (15.2%) cases. Similarly, Saeed and
have
also
reported
that
lymphoma were the second common
diagnostic report
(18)
. Bone marrow was
not involved in 27 (72.9%) cases and
marrow involved by lymphoma was
found
in
10
in this study. The diagnosis of ITP is
made after exclusion of other causes of
low platelet count. Other studies were
showed 15.7%, 10.5% and 6.21% cases
In this study, the second common
Jawhar
ITP was seen in 21 (8.6%) cases
(27.1%)
cases.
All
specimens of involved marrow were non
Hodgkin's lymphoma and the majority of
these cases were diffuse large B cell
of ITP in Pudasaini et al, Kibria et al
and
Khan et al respectively (17,20,21).
Myeloproliferative neoplasms were
commonly diagnosed on bone marrow
examination
and
confirmed
by
estimation of Janus-associated kinase 2
(JAK2) mutations
(14)
. MPN was found
in 21 (8.6%) cases. This is nearly similar
to another study which was done by
Saeed and Jawhar in Mosul18, while
other study was showed low percentage
of MPN that found in (2.7%) cases and
was published in Yemen (22).
lymphoma. Similar results were reported
by Durosinmi et al from Nigeria (19).
Another
Active bone marrow was 3rd
common diagnosis in the present study
and found in 24 (9.8%) cases. High
percentage
of
active
marrow
125
(35.1%) cases was reported in a study
from Kenya. These were due to over
induction of bone marrow examination
common
disorder
in
present study was chronic lymphocytic
leukemia and was found in 13 (5.3 %)
cases. Similarly, 2 (5%) cases were seen
in another study done in India15.
However in a study done by Chandra,
3.1% of cases were CLL23. This might
be related to geographical variation.
104
Chronic myeloid leukemia was
found in 12 (4.9%) cases and was the
least common leukemia in studied cases
constituting (13%) of all leukemia in this
study and it is nearly similar to the fact
that CML accounts for around 15% of
leukemias (14).
finding (0.7% of cases with secondary
metastasis) (25).
In present study, 6 (2.4%) cases
were not diagnosed on bone marrow
examination as two of them were with
inadequate trephine biopsy and the
remaining 4 cases were with inadequate
Multiple myeloma was another
hematological
malignancy
that
of both aspiration and biopsy. Higher
frequency
(14.4%
cases)
of
non
diagnosed by bone marrow examination
diagnostic sample was found in another
with other diagnostic criteria and it was
study (26).
found in 12 (4.9%) patients with mean
age 61 years and all cases were
associated with high ESR. Other studies
were reported a frequency of multiple
myeloma as 5.6%, 4% and 3.5%
respectively (17,2,24).
marrow
marrow
study showed that
aspirations
was
failed
bone
to
obtained in 10 (4.08%) cases in which
touch imprint and adequate trephine
biopsies were well done, this is known
as dry tap or blood tap. The main causes
Another important indication for
bone
This
was
technique (active marrow biopsy) in 3
detection of secondary metastasis. In
(30%) cases and acute leukemia (packed
this study, 8 (3.2%) cases of tumors (4
cells in trephine biopsy) in 3 (30%)
cases of neuroblastoma, 2 cases of
cases. A similar study was done by
Ewing
of
Humphries in 1990, who reported a rate
adenocarcinoma of prostate and 1 case
of dry tap as (3.9%)9 and higher
of
were
frequency was recorded by Khanum et al
underwent bone marrow examination to
in Lahore and found in 50 (10%) cases
exclude
among
sarcoma,
hepatocellular
examination
of dry tap in present study were faulty
1
case
carcinoma)
marrow involvement.
The
500
studied
patients8.
The
marrow involvement by secondary
remaining cases of dry tap were
metastasis was found in 2 (0.8%) cases.
myelofibrosis in 2 cases, secondary
A study from Lahore reported a similar
metastasis and hairy cells leukemia.
105
In this study, complications after
2.
Okinda NA and Riyat MS. Bone
both procedures (marrow aspiration and
marrow examination finding at Aga
trephine biopsy) were not encountered.
KhanUniversity hospital, Nairobi. East
Complications
Afri Med J 2010; 87(1): 4-8.
of
bone
marrow
examination are rare as reported by Bain
et al (27).
S, Chesney A, Clark BD, et al. Bone
Conclusion:
Marrow
We concluded that bone marrow
examination is an important diagnostic
tool in the diagnosis and staging of
various hematological disorders. The
main
indication
for
bone
marrow
examination in this study was presence
of blast cells in peripheral circulation
(Acute
3. Riley RS, Williams D, Ross M, Zhao
leukemia).
The
commonest
causes of dry tap in this study were
faulty technique and packed cell in acute
Aspirate
Pathologist's
and
Biopsy:
Perspective.
A
II.
Interpretation of the Bone Marrow
Aspirate and Biopsy. J Clin Lab Anal
2009;23(5):259-307
4. Bain BJ. Bone marrow aspiration. J.
Clin. Pathol 2001a; 54: 657-663.
5. Bain BJ. Bone marrow trephine
biopsy. J. Clin. Pathol 2001b; 54: 737742.
leukemia. Bone marrow examination in
6. Bain BJ.
spite of being invasive procedure it is
morbidity and mortality. Br J Haematol
safe and post operative complications
2003; 121: 949– 951.
were not recorded in this study.
Bone marrow biopsy
7. Marti J, Anton E, Valenti C.
Complications of bone marrow biopsy.
Br. J. Hematol.2004; 124(4): 557–558.
References
1. Toi PC, Varghese RG, Rai R.
Comparative
Evaluation
of
Simultaneous Bone Marrow Aspiration
and
Bone
Marrow
Biopsy:
8. Khanum F, Rehman AU, Ahmad S,
Anwar J. `Dry tap` of bone marrow and
its clinical important. Pak J Med Health
Sci 2007; 1- 3.
An
Institutional Experience. Ind. J. Hematol
9. Humphries JE. Dry tap bone marrow
Blood Transfus 2010; 26(2): 41-44.
aspiration: clinical significance. Am J
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Hematol 1990; 35 (4): 247 – 250.
disorders. J k science 2010; 12(3): 130-
(Abstract)
133
10. Islam A. Bone marrow aspiration
before bone marrow core biopsy using
the same bone marrow biopsy needle: a
good or bad practice? J Clin Pathol
2007; 60: 212 – 215.
11.
Bashawri
LA.
Bone
marrow
examination; indication and diagnostic
value. Saudi Med J 2002; 23(2): 191196.
Ewuga OJ. Epidemiology of Anaemia
Necessitating Bone Marrow Aspiration
Cytology in Jos. Niger Med J 2009;
50(3): 61 – 63 (Abstract)
17. Pudasaini S, Prasad KBR, Rauniyar
SK, Shrestha R, Gautam K, Pathak R, et
al.
Interpretation
of
bone
marrow
aspiration in hematological disorder. J
Path Nepal 2012; 2: 309-312.
12. Al- Gwaiz LA. Analysis of 3494
bone marrow examinations in a referral
hospital: indications and interpretations.
Saud Med J 1997; 18: 144- 147
Bates I. The role of bone marrow
aspirate
and
hematological
trephine
samples
diagnosis
in
in
patients
referred to a teaching hospital in Ghana.
Ghan Med J.2013; 47(2): 74- 78.
14. Hoffbrand AV, Moss PAH and Pettit
Essential Hematology.
18. Saeed MS, Jawhar NM. Bone
marrow trephine is some hematological
and non hematological disorders. Ann.
Coll. Med. 2010; 36(1& 2): 63 – 71.
13. Bedu-Addo G, Amoako YA and
JE.
16. Egesie OJ, Joseph DE, Egesie UG,
5th ed.
Oxford, UK: Wiley-Blackwell 2006. PP
238.
15. Gupta N, Kumar R, Khajuria A.
Diagnostic assessment of bone marrow
19. Durosinmi MA, Mabayoje VO,
Akinola NO. A review of histology of
bone marrow trephine in malignant
lymphoma. Niger J Med 2003; 12(4):
198- 201. (Abstract)
20. Kibria SG, Islam MDU, Chowdhury
ASMJ, Ali MY, Haque MR, Mustanzid
SM, et al. Prevalence of hematological
disorder: A bone marrow study of 177
cases in a private hospital at Faridpur.
Faridpur Med Coll J 2010; 5(10): 11- 13.
aspiration smears, touch imprints and
21. Khan A, Aqeel M, Khan TA, Munir
trephine
A. Pattern of hematological diseases in
biopsy
in
haematological
107
hospitalized paediatric patients based on
26. Naznin M, Wahab AJ, Kalavathy R.
bone marrow examination. J Postgrad
A review of bone marrow examinations
Med Inst 2008; 22(3): 196- 200.
in Tengku Ampuan Afzan hospital
22.
Al-Ghazaly
J,
Al-Selwi
AH,
Abdullah M, Al-Jahafi AK, Al-Dubai W,
(HYAA), Kuantan. Pahang. Med. J.
Malaysia 2006; 68 (4).
Al-Hashdi A. Pattern of haematological
27- Bain BJ, Clark DM, Wilkins BS.
diseases diagnosed by bone marrow
The normal bone marrow. In: Bone
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Marrow Pathology. 4th ed. UK; Oxford:
country experience. Clin Lab Haematol
Wiley-Blackwell 2010. pp: 40- 51.
2006;28:376-81
23. Chandra S
and Chandra H .
Comparison of bone marrow aspirates
cytology, touch imprint cytology and
trephine
biopsy
for
bone
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24. Tariq M, Khan N, Basri R, Amin S.
Nawsherwan Sadiq Mohammad
Aetiology of pancytopenia. Professional
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25. Khan FS and Hasan RF. Bone
Pathology Department; College of Medicine
/ Hawler Medical University
marrow examination of pancytopenic
children. J Pak Med Assoc 2012; 62(7):
Mob: 00964(0)7504384101
660- 663.
108
‫‪Evaluation the Role of Bone Marrow Examination‬‬
‫‪Shorsh J. R, Nawsherwan S.M, Hoger I.M.S.‬‬
‫تقييم دورفحص نخاع العظم في تشخيص أمراض الدم في مراكز أمراض الدم و األورام في إقليم‬
‫كردستان‬
‫شورش جميل رضا ‪ ،1‬نوشيروان صادق محمد ‪،2‬هوكر إسماعيل محمد سرهنك ‪3‬‬
‫‪- MBChB 1‬ماجستير أمراض الدم ‪ /‬مستشفى هيوا التعليمي‬
‫‪ FICMS - MBChB 2‬أمراض الدم ‪ /‬قسم علم األمراض‪/‬كلية الطب ‪/‬جامعة هولير الطبية البريد اإللكتروني‪:‬‬
‫‪[email protected]‬‬
‫‪- MBChB 3‬ماجستير أمراض الدم ‪ /‬مستشفى أربيل التعليمي‬
‫الملخص‬
‫الخلفية‪ :‬لعينة نخاع العظم والخزعة دورا هاما في تقييم وتشخيص معظم أمراض الدم وبعض االضطرابات غير‬
‫الدموية‪ .‬األهداف‪ :‬هدف هذه الدراسة هو لتقييم قيمة فحص نخاع العظام في تشخيص األمراض الدموية وتحديد تواتر‬
‫وأسباب نخاع العظم الجاف‪.‬‬
‫المرضى والطرق‪ :‬هذه دراسة استطالعية فقط وتمت خالل الفترة من يناير ‪ 2113‬إلى يونيو ‪ 2113‬في مستشفى‬
‫هيوا التعليمي هيوا و مستشفى أربيل التعليمي في السليمانية وأربيل على التوالي‪ .‬وكان عدد إجمالي من ‪ 242‬حالة‬
‫خضعت فحص نخاع العظام‪ .‬وقد استخدم لمس الخزعة في حالة النخاع الجاف‪ .‬وقد استخدم صبغة السودان في‬
‫سرطان الدم الحاد‪.‬‬
‫النتائج‪ :‬كان عدد المرضى ‪ )٪2..3( 131‬من الذكور و ‪ )٪43.1( 111‬من اإلناث‪ ،‬تتراوحت أعمارهم ‪11-1‬‬
‫سنوات‪ ،‬وكان متوسط أعمارهم ‪ 24 ± 3..1‬عاما‪ .‬اكثر الحاالت شيوعا من المرضى التي خضعت للتقصي‬
‫السريري وفحص نخاع العظم كانت الشحوب (‪ ،)٪11.4‬تليها الحمى (‪ .)٪32.2‬وكانت المؤشرات الرئيسية وجود‬
‫الخاليا السرطانية في الدم ‪ ،)٪21.2( .6‬يليها تقييم نخاع العظام لتحديد مرحلة سرطان الغدد الليمفاوية ‪31‬‬
‫(‪ .)٪12.1‬وكانت التشخيصات الشائعة كاالتي‪ :‬سرطان الدم الحاد ‪ ،)٪21.2( .6‬ونخاع نشط (السلبي ليمفوما) ‪21‬‬
‫(‪ ،)٪11.1‬ونخاع نشط ‪ .)٪6.1( 24‬وكانت نسبة النخاع الجاف (‪ )٪4.11‬وكانت األسباب األكثر شيوعا‪ :‬سرطان‬
‫الدم الحاد وتقنية خاطئة (نخاع العادي)‪.‬‬
‫الخالصة‪ :‬فحص نخاع العظم هو أداة تشخيصية مهمة في تشخيص وتحديد مراحل مختلفة من االضطرابات الدموية‪.‬‬
‫كلمات البحث‪ :‬نخاع العظم ‪ ،‬خزعة‪ ،‬أمراض الدم‪ ،‬كردستان‬
‫‪109‬‬
Table 1 : Indications for bone marrow examination:
Indication
Frequency
Percentage
Blast cells in peripheral circulation
69
28.2
Bone marrow for lymphoma staging
37
15.2
Anemia
24
9.8
Pancytopenia
20
8.1
Thrombocytopenia
19
7.7
Bicytopenia
15
6.1
Leucocytosis
14
5.6
Polycythemia
14
5.6
Lymphocytosis
13
5.2
Thrombocytosis
6
2.4
Hepatosplenomegaly with anemia
4
1.6
Leucoerythroblastic anemia
2
0.8
To exclude marrow metastasis
8
3.2
Total
245
100
110
Table 2: Results of Bone marrow examination of the studied cases.
Disorders
Number of cases
%
ALL
40
16.3
AML
29
11.8
Active marrow (negative for lymphoma)
27
11.1
Active marrow
24
9.8
Idiopathic thrombocytopenia purpura
21
8.6
Myeloproliferative neoplasm
21
8.6
Chronic lymphocytic leukemia
13
5.3
Chronic myeloid leukemia
12
4.9
Multiple myeloma
12
4.9
Marrow involvement by lymphoma
10
4.1
Aplastic anemia
10
4.1
Non – diagnostic
6
2.4
Active marrow (negative for solid tumors)
6
2.4
Megaloblastic anemia
5
2
Secondary metastasis
2
0.8
Pure red cell aplasia
2
0.8
Erythroid hyperplasia
2
0.8
Myelodysplastic syndrome
2
0.8
Hairy cells leukemia
1
0.4
Total
245
100
111
Table 3: Indication of bone marrow examination versus final diagnosis
Indication
Acute leukemia
Frequency Final diagnosis
69
ALL
AML
Bone marrow for staging
37
Anemia
24
Pancytopenia
20
Thrombocytopenia
Bicytopenia
19
15
Leucocytosis
14
Polycythemia
Lymphocytosis
14
13
Thrombocytosis
6
Hepatosplenomegaly and
anemia
Leucoerythroblastic
anemia
To
exclude
marrow
metastasis
Total
4
2
8
Cases
40
29
Active
marrow
(negative
lymphoma)
Marrow involved by lymphoma
Active marrow
Multiple myeloma
Erythroid hyperplasia
Pure red cells aplasia
Aplastic anemia
Multiple myeloma
Non diagnosis marrow
Active marrow
Hairy cell leukemia
ITP
Active marrow
Multiple myeloma
ITP
CLL
Non diagnostic marrow
CML
Active marrow
CLL
Active marrow
Active marrow
Active marrow
for 27
10
Active
marrow
(negative
metastasis) Secondary metastasis
for 6
2
245
245
13
7
2
2
10
4
2
2
1
1
19
5
3
2
2
1
1
1
12
1
1
14
12
1
5
1
2
2
2
112
Figure 1:(A) Acute lymphoblastic leukemia.(B) Acute Myeloblastic Leukemia.
Marrow aspiration (Leishmann stain)
Figure 2 : Causes of dry tap in this study.
113
Original article
Types of Anaemia and its Correlation with Disease Activity in Patients
with Rheumatoid Arthritis among Kurdish Population of Iraq
Hisham A. Getta¹, Najmaddin Khoshnaw ²* & 6, Alaa Fadhil Alwan 3 ,Sundus F.A4,
Raouf R. Mirza 5
¹ Department of hematopathology, faculty of sciences, school of medicine, university of sulaimani,
Kurdistan region, Iraq
²*Department of Hematology, Hiwa Hospital, Sulaymaniyah, Kurdistan Region, Iraq
3
Department of clinical hematology, the national center of hematology, Almustansiriya University,
Baghdad, Iraq
4
Department of rheumatology and medical rehabilitation, general medical teaching hospital, Sulaymaniyah,
Kurdistan Region, Iraq
5
Department of rheumatology and medical rehabilitation, school of medicine, university of sulaimani,
Sulaymaniyah Kurdistan region, Iraq
6
Kurdistan Board of Medical Specialties, Clinical Hematology/Trainee, Ministry of higher education and
scientific research, Erbil, Kurdistan Region, Iraq
Received 8/1/2016
revised 3/2/2016
accepted 23/2/2016
114
Types of Anaemia and its Correlation with Disease
Hisham A.Getta, Najmaddin Khoshnaw et al
Abstract:
Background: Rheumatoid arthritis (RA) is a chronic systemic inflammatory autoimmune disease
characterized by articular and extra-articular manifestation as weight loss, fatigue, malaise, and
anemia.
Objectives: The aim of this study was to find the prevalence of different types of anemia and its
correlation with the disease activity among patients with RA in Sulaymaniyah province and to
determine the associated risk factors.
Patients and Methods: A cross sectional study carried out in Sulaymaniyah general medical
Hospital for periods from October-2014 to the end of June-2015.A convenient sample of 100
rheumatoid arthritis patients were selected from patients seen in the rheumatology clinic. One
hundred healthy voluntary controls of same age groups were selected and same parameters for
diagnosis of anemia are used in both groups.
Results: The prevalence of all types of anemias among the rheumatoid Arthritis (RA) patients
was 40% which more than that found in control group. The common types of anemia was anemia
of chronic disease (28%), iron deficiency (10%), thalassemia minor (1%), and megaloblastic
anemia 1%. We found a significant correlation of RA with each low hemoglobin, low hematocrit,
high leucocyte count and high ESR. Anemia among RA patients in our study was significantly
more prevalent among low socioeconomic status patients. The majority of RA patients had
moderately or high active disease, which revealed no association between disease activity and
anemia (p value=0.3).
Conclusion: the prevalence and types of anemias among RA patients in Sulaymaniyah was
comparable to that found in other studies and it was two times common than the normal healthy
peoples. In our study we concluded that little evidence found between disease activity and
anemia.
Keywords: Rheumatoid Arthritis, Anemia, Sulaymaniyah, Kurdistan Region, Iraq
Introduction:
Rheumatoid arthritis (RA) is chronic
systemic
auto-immune
inflammatory
RA is associated with a high risk for
morbidity
and
premature
death
disease characterized by articular and
secondary to the earlier development of
extra-articular manifestation, such as
cardiovascular,
weight
anemia
loss,
(1)
fatigue,
malaise
and
malignancy
(2)
lung
diseases
and
.
.
115
Extra-articular manifestations of RA
with the number of active inflamed
occur in about 40% of patients, either in
joints
the beginning or during the course of
sometimes observed
their disease
(3)
.
(8)
.
Lymphadenopathy
is
in active
RA,
usually presenting on biopsy as benign
(9)
Patients with RA, who have high titers
follicular hyperplasia
of rheumatoid factor, are most likely to
anemia in RA may include anemia of
have extra-articular manifestations of
chronic disease, iron-deficiency anemia,
their disease
present
(4)
. Patients with RA may
with
hematological
abnormalities either at the time of
diagnosis, or during the course of their
illness. Hematological manifestations in
RA can be broadly categorized into areas
of anemia, thrombocytosis, neutropenia,
thrombocytopenia,
eosinophilia,
hematological malignancies
(5)
and
. Anemia
is, by far, one of the most common
extra-articular manifestations of RA.
The
cause
of
multifactorial
activity,
anemia
including
drug-induced,
in
RA
is
disease
nutritional,
gastrointestinal bleeding, bone marrow
suppression,
erythropoiesis
and
(6)
ineffective
. Anemia of chronic
disease (ACD) usually normochromic
normocytic type observed in RA, where
it usually correlates with the disease
activity. Eosinophilia in RA reflects
active disease or hypersensitivity to
drugs
(7)
. Thrombocytosis is a frequent
finding in active RA and is correlated
vitamin
deficiency
. The types of
anemia,
anemia, or hemolytic anemia
aplastic
(10)
.
The first principle of treating RA
associated
anemia
is
to
reduce
inflammation as much as possible using
non-steroidal anti-inflammatory drugs
(NSAIDS),
anti
disease
modifying
rheumatoid
drugs
(DMARDs). Erythropoietin stimulating
agents (ESA) therapy has been shown to
be effective in treating RA induced
ACD. However, RA patients tend to
have a blunted response to ESA therapy,
and higher than normal ESA doses are
often required. In these patients, ACD
shows improvement when inflammation
has decreased. When iron deficiency
occurs concomitantly with ACD, iron
repletion may be needed, either alone or
as adjunct therapy with ESAs. ESA
therapy
in
combination
with
iron
supplementation corrects anemia in most
patients with RA, and may improve RA
outcomes and quality of life
(11)
.The
116
aims of this study were to find the
prevalence, types of anemia among
patients with RA in Sulaymaniyah and to
determine the associated risk factors.
met
A cross sectional study carried out in
General
General
Hospital
Hospital.
Inclusion criteria:
Sulaymaniyah
Rheumatology ward of Sulaymaniyah
in
the
All patients who
2010
ACR-EULAR
classification criteria for Rheumatoid
Arthritis were included
(12)
(table1), a
Sulaymaniyah governorate for period
score of ≥6/10 is needed for diagnosis of
from 1st of October, 2014 to the end of
patient as having RA.
June, 2015. It included 100 patients with
RA who attended to Rheumatology
Consultation clinic or admitted to
Table 1 : criteria for diagnosis of RA
A.Joint involvement
SCORE
1 large joint
0
2- 10 larg joint
1
1-3 small joints(with or without large joint)
2
4-10 small joints(with or without large joint)
3
>10 joints(at least 1 small joint)
5
A.Serology(at least 1 test result is needed for classification)
Negative RF and Anti ccp
0
Low positive RF and Anti ccp
2
High positive RF and Anti ccp
3
C.Acute phase reactants
Normal CRP and ESR
0
Abnormal CRP and ESR
1
D.Duration of symptoms
Less than 6 weeks
0
6 weeks or more
1
N.B : A score of ≥6/10 is needed for diagnosis of patient as having RA
117
Exclusion
criteria:
Any cause
of
by HPLC (high performance liquid
anemia not related to RA which includes
chromatography,
patients with active GIT bleedings,
Health Organization (WHO) criteria
bleeding
were
tendencies,
malignancies,
patients,
menorrhagia,
renal failure,
chronic
diabetic
infections
excluded in our study.
were
used
to
D10)
The
define
World
anemia
as
hemoglobin threshold of <120 g/L for
women and <130 g/L for men
(13)
. The
The data were
disease activity evaluated according to
collected through direct interview and
DAS-28 in which values less than 2.6
using
corresponds
prepared
questionnaire.
The
for
clinical
remission,
known cases of RA were diagnosed by
values ranging (2.6-3.2) are regarded as
consultant Rheumatologist. Full medical
low disease activity, values ranging(3.2-
history and clinical examination were
5.1) are regarded as moderate disease
done for all patients. A total of 100
activity and more than 5.1 regarded as
healthy controls were selected and
high disease activity. All patients gave
required information was collected from
their oral consent before beginning of
them. The questionnaire included: socio-
the study and agreement was taken from
demographic characteristics as Age,
official review ethical committee of
gender, residence and socioeconomic
Sulaymaniyah General Hospital.
status.
RA
characteristics:
disease
activity assessed by DAS-28, rheumatoid
factor
(RF)
and
duration of RA,
treatment modalities of RA, family
history of RA and anemia, Laboratory
tests done as complete blood count,
blood smear, reticulocyte count, coombs
test and ESR done by autoanalyzer,
serum
iron
and
TIBC
done
by
C111Cobas Roche Company, serum
ferritin, serum B12, and folate by E411
Cobas
Roche
Company,
Hb-
electrophoresis done for selected cases
Statistical analysis: Statistical Package
for Social Sciences (SPSS) version 20
was used. Descriptive statistics presented
as (mean ± standard deviation) and
frequencies as percentages. Chi-square
used
for
categorical
variables
and
Fishers exact test was used when
expected variables were less than 20%.
Independence t-test was used to compare
between two means. In all statistical
analysis, level of significance (p value)
set at ≤ 0.05.
118
Results:
A total of 100 patients with RA were
More than half of RA patients were
included in present study with mean age
living in urban areas. The socioeconomic
50±13 years, 52% of them were ≥ 50
status was presented as following; 21
years. Female were more than males
patients were good, 44 were fair and 35
with male to female ratio of 1:9.01.
RA patients had low socioeconomic
status as shown in (table 2).
Table 2: Sociodemographic characteristics of RA patients.
Variable
No.
%
20-29 years
8
8.0
30-39 years
12
12.0
40-49 years
28
28.0
≥ 50 years
52
52.0
Male
9
9.0
Female
91
91.0
Urban
52
52.0
Rural
48
48.0
Good
21
21.0
Fair
44
44.0
Low
35
35.0
Age mean±SD (50±13 years)
Gender
Residence
Socioeconomic status
Mean RA disease duration was 11±9
The treatment types used by RA patients
years, 65% of RA patients had disease
were
duration ≤ 10 years. The Rheumatoid
prednisolone
factor (RF) was positive for 91% of RA
(16.8%), Methotrexate (16.5%), Calcium
patients and negative for 9% of them.
& Vitamin D (14.2%), combination
distributed
as
(16.8%),
followings;
Folic
acid
119
therapy (12.5%), hydroxychloroquine
Mean Hb of RA patients was 12.3±1.4
(10.8%),
mg/dl, 40% of them had low Hb level.
Alendronate
(2.6%),
Leflunomide (2.3%), Etanercept (3.1%),
Mean
PCV
of
RA
patients
was
Rituximab (1.3%), Adalimumab (0.4%),
40.1±30.8 %, 33% of them had low PCV
and Azathioprine (0.4%). Mean DAS-28
level. Mean WBC of RA patients was
of RA patients was 5±1.2, while 57% of
8.4±2.9 x109, 20% of them had high
RA patients had high disease activity.
WBC count as shown in table 3.
Table 3: hematological parameter of patient with RA
Variable
No.
%
Normal
60
60.0
Low
40
40.0
Total
100
100.0
Normal
67
67.0
Low
33
33.0
Total
100
100.0
Normal
80
80.0
High
20
20.0
Total
100
100.0
100
100
100
100
Hb mean±SD (12.3±1.4 mg/dl)
PCV mean±SD (40.1±30.8 %)
WBC mean±SD (8.4±2.9 x109)
Platelets mean±SD (259.9±65.9x109)
Normal
Reticulocytes
level
normal
Anemia was found in 40 patients
deficiency
anemia
IDA,
2.5%
(40%) with RA patient and 70.0% of
megaloblastic anemia and 2.5% had
anemic patients had anemia of chronic
Thalassemia
diseases
(ACD),
25%
had
minor
(Fig
1).
iron
120
No.
30
25
20
15
10
5
0
28
10
1
1
Figure 1: Types of anemia among RA patients.
Mean serum iron of anemic RA patients
Coombs test. Mean ESR of RA patients
was 98.4±35.9 µg/dl, with 72.5% had
was 46.3±19.3 mm/hr, all of RA patients
low iron level. Mean TIBC level of
had high ESR.
anemic RA patients was 385.9±67.9
No
significant
differences
were
µg/dl, with 47.5% had low TIBC level
observed between anemic and non-
and 20% had high TIBC level. Mean
anemic RA patients regarding DAS-28
serum ferritin of anemic RA patients was
and rheumatoid factor (RF) (p>0.05). No
73.3±56.1 ng/ml, with 22.5% had low
significant differences were observed
ferritin level while 25% had high ferritin
between anemic and non-anemic RA
level. Only one patient had low B12
patients regarding family history of RA
level. Hb-electrophoresis was positive
and anemia (p>0.05)
only for one patient. All of RA patients
(table 4)
as shown in
had normal folate level and negative
121
Table 4: Distribution of RA characteristics according to anemia.
Variable
Anemic
Non anemic
No.
%
No.
χ²
P
3.0*
0.3
3.4*
0.06
2.3
0.1
0.9*
0.3
%
DAS28
Remission
0
-
1
100.0
Low activity
3
50.0
3
50.0
Moderate activity
11
30.6
25
69.4
High activity
26
45.6
31
54.4
RF
Sero +ve
39
42.8
52
57.2
Sero –ve
1
11.1
8
88.9
Family history of RA
Positive
15
51.7
14
48.3
Negative
25
35.2
46
64.8
Family history of anemia
Positive
2
66.7
1
33.3
Negative
38
39.2
59
60.8
*Fishers exact test.
Discussion:
Rheumatoid
autoimmune
arthritis
(RA)
disorder
of
is
an
normochromic
and
normocytic
type.
unknown
Anemia is multifactorial, reflected in
etiology characterized by symmetric,
dimorphic appearance and wide red cell
erosive synovitis and, in some cases, extra
distribution width. Anemia of chronic
articular
disease
involvement.
Extra-articular
(ACD)
and
iron
deficiency
manifestations can be detected in almost
anemia (IDA) are the most important
any organ system, causing considerable
types of anemia in RA patients (14).
disease related morbidity and interference
In this study, prevalence of anemia
with quality of life. Anemia is a
among studied RA patients was (40%).
frequently
The result was close to that of Wilson A
occurring
extra-articular
manifestation of RA, being mostly of the
et al
(15)
who reported the anemia to be
122
(22)
ranged of 33-66% among RA patients, but
Swaak A study
was higher than that reported by Muia
bases
GM, et al in which he reported prevalence
released during ACD can alter systemic
of 33%
(16)
that
, this explained on
inflammatory
cytokines
. On other hand, other studies
iron metabolism by inducing excess
found higher prevalence which reached
synthesis of hepcidin, the iron regulatory
up to 70.6% (17).
hormone. Since hepcidin inhibits iron
Prevalence ratio of developing anemia
export from cells by blocking ferroportin
among RA patients was 2:1 as compared
activity, excess hepcidin is the root cause
to healthy controls. This prevalence ratio
of the hypoferremia and iron-restricted
is close to that reported by Han C, et al
erythropoiesis seen in ACD (23), (24).
study who reported a prevalence ratio of
anemia among RA patients as 2.2.:1(18)
In this study we found that mean age
of RA patients was 50±13 years with
In this study we have found no
predominance of female gender. This is
significant association between disease
consistent with results of Muia et al study
activity and anemia (p value=0.3) ,while
(16)
in other epidemiological study it was
rural living and low socioeconomic status
reported that lower hemoglobin levels
(P≤0.05). This is similar to results of
was associated with increased disease
Putrick P, et al study (25).High levels ESR
activity as measured by the number of
and WBC were significantly associated
tender and swollen joints, ESR, CRP
with RA patients (P≤0.05). This finding
level, and assessments of pain and
was close to that of Shenair D, et al study
fatigue(DAS-28 score)(19). Han C et al
(26)
reported
independently
had high DAS28 activity. This finding is
physical disability in
higher than that reported by Ganna S
that
contributes to
anemia
patients with RA (20).
More than two thirds of detected
. RA was significantly associated with
. More than half of studied RA patients
study (24) which reported that 30% of RA
patients had high DAS-28 activity.
anemic RA cases in present study were
Anemia among RA patients in our
anemia of chronic diseases (ACD) and
study was significantly more prevalent
25% of them were iron deficiency anemia
among
(IDA). This result was close to many
patients (P=0.05). This finding was close
studies as Ravindran V, et al study (21) and
to that of Gordon MM, et al study (27).
low
socioeconomic
status
123
Bengtsson et al reported the association
have more severe joint disease and if the
between
and
anemia is successfully treated, the joint
educational status and a lower risk for
disease will likely respond to treatment as
the development of RA in a population
well (15).
high
socioeconomic
representative
of
the
population,
suggesting
Swedish
that
environmental factors or lifestyle might
influence disease evolution (28). Pedersen
et al reported that the educational level
was inversely associated to the risk of
developing RA in the Danish population
and the risk was twice as lower for those
individuals with a higher number of
years of formal schooling (29).
Platelets level among RA patients was
normal, although, mean platelets among
Conclusion:
The prevalence of anemia among RA
patients
in
Sulaymaniyah
was
comparable to that found in other studies
and it was two times common than the
normal healthy peoples. Anemia of
chronic diseases was the most common
type of anemia among RA patients. The
majority of RA patients had moderately
or high active disease, which revealed no
association between disease activity and
anemia.
anemic patients was significantly higher
than that of non-anemic (P=0.03). This is
consistent with results of Safak S, et al
study
(30)
. ESR level was significantly
increased among anemic RA patients in
our study (P<0.001). This is similar to
results of Ganna S study(24). Recent
studies have revealed a key role of
cytokines
and
other
mediators
of
inflammation in the development not only
of the articular syndrome, but also a
whole range of systemic manifestations of
the disease
(31)
. Wilson A, et al in their
Acknowledgment:
We have special thanks to all doctors
and medical staffs and all patients and
peoples who helped us in collecting the
data for this study.
Authorship contribution:
HAG who designed the project of the
study, RRM supervisor of the research
article, SFA primary investigator, NK
and AFA shared in rewriting and editing
of the all parts of the manuscript.
systematic review, suggested that patients
with RA who have anemia are likely to
124
Conflict of interest:
All authors declare that there is no any
conflict of interest in publishing this
article.
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status and the risk of developing
rheumatoid arthritis: results from the
Swedish EIRA Study. Ann Rheum Dis
2005; 64:1588-94.
29. Pedersen M, Jacobsen S, Klarlund
M, Frisch M. Socioeconomic status and
risk of rheumatoid arthritis: a Danish
case-control study. J Rheumatol 2006;
33:1069-74.
30. Safak S, Uslu AU, Serdal K, Turker
T, Soner S, Lutfi A. Association between
mean platelet volume levels and
inflammation in SLE patients presented
with arthritis. African Health Sciences
2014; 14 (4):919-924.
31. Choy EH, Panayi GS. Cytokine
pathways and joint inflammation in
rheumatoid arthritis. N Engl J Med
2001; 12:907-916.
Correspondence to :
Dr. Najmaddin Khoshnaw
Clinical Hematologist, Department of
Hematology
Hiwa Hospital -Sulaymaniyah -IRAQ
Cell phone: +9647701554184
Po. Box: 54
127
‫‪Hisham A.Getta, Najmaddin Khoshnaw et al‬‬
‫‪Types of Anaemia and its Correlation with Disease‬‬
‫أنواع فقر الدم وارتباطها مع نشاط المرض في المرضى الذين يعانون من التهاب المفاصل الرثوي‬
‫بين السكان األكراد في العراق‬
‫هشام جتا ‪ ،1‬نجم الدين خوشناو ‪ ،6 &2‬عالء فاضل علوان ‪ ،3‬سندس ف ‪ , 4‬رؤوف ميرزا ‪5‬‬
‫‪ 1‬قسم امراض الدم‪ ،‬كلية العلوم‪ ،‬كلية الطب‪ ،‬جامعة السليمانية‪ ،‬إقليم كردستان‪ ،‬العراق‬
‫‪ 2‬قسم أمراض الدم‪ ،‬مستشفى هيوا‪ ،‬السليمانية‪ ،‬كردستان‪ ،‬العراق‬
‫‪ 3‬قسم أمراض الدم السريري‪ ،‬المركز الوطني لألمراض الدم‪ ،‬الجامعة المستنصرية‪ ،‬بغداد‪ ،‬العراق‬
‫‪ 4‬قسم الروماتيزم والتأهيل الطبي‪ ،‬المستشفى العام التعليم الطبي ‪,‬السليمانية وإقليم كردستان‪ ،‬العراق‬
‫‪ 5‬قسم الروماتيزم والتأهيل الطبي‪ ،‬كلية الطب‪ ،‬جامعة السليمانية‪ ،‬السليمانية اقليم كردستان العراق‬
‫‪ 6‬مجلس كردستان للتخصصات الطبية والسريرية أمراض الدم ‪ /‬متدرب وزارة التعليم العالي والبحث العلمي‪،‬‬
‫أربيل‪ ،‬إقليم كردستان‪ ،‬العراق‬
‫الخلفية‪ :‬التهاب المفاصل الروماتويدي هو من أمراض المناعة الذاتية والتهاب مزمن يتميز باعراضه المفصلية‬
‫الدم‪.‬‬
‫وفقر‬
‫بالضيق‪،‬‬
‫والشعور‬
‫والتعب‪،‬‬
‫الوزن‪،‬‬
‫كفقدان‬
‫المفصلية‬
‫وخارج‬
‫األهداف ‪ :‬الهدف من هذه الدراسة تتمثل في العثور على انتشار أنواع مختلفة من فقر الدم وعالقته مع نشاط المرض‬
‫بين المرضى الذين يعانون من التهاب المفاصل الروماتويدي في محافظة السليمانية وتحديد عوامل الخطر المرتبطة‬
‫بها‪.‬‬
‫المرضى والطرق‪ :‬تم اختيار دراسة مقطعية أجريت في مستشفى عام السليمانية للفترة من أكتوبر ‪ 2114‬إلى نهاية‬
‫يونيو‪ .2115-‬عينة مالئمة من ‪ 111‬مريض يعانون من التهاب المفاصل الروماتويدي من المرضى الذين تم فحصهم‬
‫في عيادة الروماتيزم‪ .‬وقد تم اختيار مائة من الضوابط الطوعية الصحية من الفئات العمرية نفسها‪ ،‬استخدمت نفس‬
‫المجموعتين‪.‬‬
‫كال‬
‫في‬
‫الدم‬
‫فقر‬
‫لتشخيص‬
‫المعايير‬
‫النتائج‪ :‬كان معدل انتشار جميع أنواع فقر الدم بين المرضى المصابين بالتهاب المفاصل الروماتيزمي (‪ )%41‬أكثر‬
‫من تلك الموجودة في المجموعة الضابطة‪ .‬وكانت األنواع الشائعة من فقر الدم فقر الدم الناجم عن األمراض المزمنة‬
‫(‪ ،)٪22‬ونقص الحديد (‪ ،)٪11‬الثالسيميا الصغرى (‪ ،)٪1‬وفقر الدم الوبيل( ‪ .)٪1‬لقد وجدنا ارتباط كبير بين‬
‫الروماتيز الرثوي مع كل من الهيموغلوبين المنخفض‪ ،‬وانخفاض الهيماتوكريت‪ ،‬وارتفاع عدد كريات بيضاء وارتفاع‬
‫راسب الدم‪ .‬كان فقر الدم بين مرضى التهاب المفاصل الروماتويدي في دراستنا بشكل ملحوظ أكثر انتشارا بين‬
‫مرضى انخفاض الوضع االجتما عي واالقتصادي‪ .‬وكانت الغالبية العظمى من مرضى التهاب المفاصل الروماتويدي‬
‫لديهم متوسط الى شديد النشاط‪ ،‬والتي كشفت عن عدم وجود عالقة بين نشاط المرض وفقر الدم (‪.)1.3 = p‬‬
‫الخالصة ‪:‬مدى انتشار وأنواع فقر الدم بين مرضى التهاب المفاصل الروماتويدي في السليمانية كان مماثلة لتلك‬
‫الموجودة في دراسات أخرى‪ ،‬وكان مرتين اكثر من الناس االصحاء‪ .‬في دراستنا خلصنا إلى أن القليل من األدلة‬
‫وفقر‬
‫المرض‬
‫نشاط‬
‫بين‬
‫وجدت‬
‫كلمات البحث‪ :‬التهاب المفاصل الروماتويدي‪ ،‬فقر الدم‪ ،‬السليمانية‬
‫‪128‬‬
Original article
A Clinical-Hematological Study of Pancytopenia Patients Attending
Nanakaly Hospital in Erbil City
Alan Isaac Isho1 , Nawsherwan Sadiq Mohammad2, Saran Abdulqadir Nooruldin3
1 MBChB-MSc Hematology/ Erbil Teaching Hospital
2 MBChB, FIBMS Hematology/ Pathology Department, College of Medicine/ Hawler Medical University/
Mob: 00964(0)7504384101
3 MBChB-MSc Hematology/ Rizgary Teaching Hospital
Received: 16/3/2016
accepted: 18/4/2016
Abstract
Background: Pancytopenia is a triad of low hemoglobin, white blood cells and platelets.
Although it is a common clinical problem with an extensive differential diagnosis, there is a
relatively little discussion of this abnormality in major textbooks of internal medicine and
hematology.
Objectives: This study aimed to determines the etiology and clinical profile of pancytopenic
patients attending Nanakaly hospital.
Materials and Methods: During a period of 6 months, 60 pancytopenic patients attended
Nanakaly hospital, their ages ranged between one-81years. A control group of 50 age-matched
apparently healthy person were tested for complete blood picture and reticulocyte count. History,
physical examination and hematological parameters at presentation were recorded. Hematological
profile included hemoglobin, total and differential leukocyte count, platelet count, reticulocyte
count, peripheral blood and marrow smears together with marrow biopsy were assessed.
Pancytopenic cancer patients on chemotherapy were excluded. Pancytopenia was defined as
hemoglobin less than 10g/dl, WBC less than 4 x109/L and platelet count less than 150 x 109/L.
Results: The mean Hb concentration, WBC count and platelet count in studied group were
significantly lower than in control group. Hematological malignancies were the commonest cause
of pancytopenia and accounted for (51.7%), they included: Acute leukemia (35%),
myelodysplastic syndrome (11.7%), hairy cell leukemia (3.3%) and myelofibrosis (1.7%).
129
A Clinical-Hematological Study of Pancytopenia
Alan I.I, Nawsherwan S.M, Saran A. N.
Aplastic and megaloblastic anemia each of them accounted for (16.7%), hypersplenism was
responsible for (10%). Other less common causes included enteric fever, kalaazar and secondary
metastasis each of them accounted for (1.7%). Pallor was present in every case. Fever was present
in (63.3%) and (25%) had bleeding manifestations at the time of presentation
.
Conclusions: The most common causes of pancytopenia were acute Leukemia, aplastic anemia
and Megaloblastic anaemia, but rare causes like myelofibrosis, enteric fever, kala azar and
secondary metastasis should also be kept in mind.
Keywords: Pancytopenia, Bone marrow, malignant hematology.
Introduction
The term pancytopenia denotes
Bone
simultaneous reduction in all the formed
examination
elements of the blood i.e, erythrocytes,
performed to every pancytopenic patient
leukocytes and platelets. Pancytopenia is
is of high diagnostic value (3). The center
not a disease entity but a triad of
of hematological diseases in Erbil,
findings that may arise from a number of
Nanakaly
disease processes
(1)
. It is, therefore
marrow
aspirate/biopsy
which
is
Hospital,
routinely
receives
many
patients whose complete blood count
exists when hemoglobin level is below
show
10 g/dl, leukocyte count below 4 x 109 /l
However, no statistical figures are
and platelet count below 150 x 109/l
available here regarding number of cases
Hence, a patient of pancytopenia may
as well as their underlying causes.
have
anaemia,
Therefore, we deemed necessary to do
weakness and dyspnoea on exertion;
our work on this group of patients to
bleeding manifestation, like skin and
determine these figures and to compare
mucosal
them with results of studies done in the
symptoms
due
bleeding,
to
due
to
thrombocytopenia; and fever, ulceration
of mouth and recurrent chest infections
due to neutropenia.(2)
pancytopenic
parameters.
other parts of Iraq and nearby countries.
The aims of this study were to
determine the spectrum of pancytopenia
with it is frequency, common clinical
presentation and etiology on the basis of
130
full clinical and laboratory examination
count, was done for every patient using
specially bone marrow examination in
automated blood counter
our locality.
Coulter® model AcT diff 2), Reticulocyte
(Beckman
preparations and Leishman’s stained
peripheral blood were prepared freshly
was
and examined for each patient. Bone
conducted during the period extending
marrow aspiration and biopsy were
from 13th Dec.2008 to 15th July 2009, at
performed at Nanakaly hospital for all
Nanakaly Hospital for Blood Diseases.
the patients. Marrow aspirate smears
A total of 60 patients with pancytopenia
were prepared, stained with Leishman’s
were included in this study. All patients
stain and examined. Marrow trephine
presenting with pancytopenia during the
biopsy specimens were fixed in Bown’s
study
For
solution and were sent to Rizgary
purposes of this work, pancytopenia was
Teaching Hospital for processing and
defined as a hemoglobin less than
interpretation.
This
prospective
period
were
study
included.
10g/dl, WBC less than 4 x109/L and
Data
were
tabulated
and
platelet count less than 150 x 109/L.
statistically analyzed using statistical
Patients who were already diagnosed
package for
cases of pancytopenia due to different
version 15). Chi square and tests of
causes
receiving
association
were
chemotherapy or therapeutic radiation,
applicable,
analysis
were excluded from this study.
(ANOVA) was used to compare between
and
those
social sciences (SPSS
used
of
whenever
variance
Diagnostic work up of cases
means of 3 groups or more of patient. A
included three basic investigations i.e. a
p-value of equal or less than 0.05 was
complete
considered as statistically significant.
blood
count,
analysis
of
stained blood, marrow aspirate smears
and bone marrow trephine biopsy.
Results
Laboratory tests were performed at the
During the period of this study, 60
Nanakaly Hospital's laboratory. Two ml
patients attending Nanakaly hospital
venous blood were collected into an
fulfilled the criteria of pancytopenia
EDTA anticoagulated tube; a full blood
according to the study protocol. There
131
were 31 males and 29 females patients.
acute lymphoblastic leukaemia and 9
Their ages ranged between one and 81
cases of acute myeloblastic leukemia.
years with a mean age of (33.3 years).
Comparing
the
various
The commonest presenting features, in
parameters among the three leading
order of frequency were: Pallor (100%
causes of pancytopenia (malignant blood
of cases), fever in (63.3%), bleeding in
diseases,
(25%) and infections in (8.3%) of cases.
megaloblastic anemia)
Organomegaly
was
noted
in
aplastic
significant
anemia
and
there
differences
were
regarding
the
(33.4%) of cases. These cases included
WBC count, where patients with aplastic
(16.7%) with splenomegaly, (11.6%)
anaemia had the lowest figures ( p <
had hepatosplenomegaly, (3.3%) had
0.04),
hepatomegaly alone and one case had
significantly lower in aplastic anaemia
lymphadenopathy. Table (1) represents a
than the other two conditions ( p<
statistical
0.001).There
summary
of
the
routine
the
platelets,
were
no
too,
were
significant
hematological parameters of studied
differences among the three groups
patients.
regarding the Hb and reticulocyte counts
Majority of
patients
showed
( p = 0.11 and p = 0.97 ) respectively.
normal red cell morphology (68.3%),
Other hematological parameters showed
macrocytosis was reported in (26.7%) of
in table 4.
cases and hypochromia was found in
(5%) of cases. All patients had marrow
aspirate
and
trephine
biopsy
Discussion
Pancytopenia
is
commonly
examinations and according to marrow
encountered in hematological practice, it
findings the causes of pancytopenia were
usually indicates a serious condition and
determined, the frequency of various
it necessitates prompt action. The pattern
causes of pancytopenia in this series is
of diseases leading to pancytopenia may
shown in table (2). Types of malignant
vary in different population groups
blood diseases are illustrated in table 3.
depending on racial factors, nutritional
Leukemic patients included 12
status and prevalence of infection
(4)
; the
males and 9 females, their mean age was
frequency of various causes varies
18 years, and there were 12 cases of
among different age groups too.
132
In this study we had 60 cases of
patients ( 71.4%) and only in (40% ) of
pancytopenia. The mean age of studied
aplastic anemia
patients was 33.3 years which is very
fever with organomegaly at presentation
close to that reported from other
favors the diagnosis of acute leukemia,
(1, 5, 6, 7, 8)
developing countries
. The
while
patients, accordingly
bleeding
unassociated
with
clinical presentation of our patients was
organomegaly is likely to be due to
classical and the relative frequencies of
aplastic anemia. In this work the mean
various
Hb concentration was 8.14 g/dl, this
presenting
features
were
comparable to the finding of other
(1, 3, 6, 7, 8, 9, 10)
workers
. Organomegaly
figure is higher than that reported by
10)
(8,
this discrepancy is due to the lower
was reported in 33.4% of studied
frequency of aplastic anemia, in which
patients,
had
anaemia is more severe, in this series
had
compared to their studies. The mean
hepatosplenomegaly and only 3.3% had
W.B.C and platelet counts (2.19 and
hepatomegaly alone. The frequency of
55.35 X 109/L respectively) were similar
splenomegaly in this study was similar
to results observed by other workers
to that reported by Ishtiaq et al from
10)
of
these
splenomegaly,
Pakistan
(7)
16.7%
11.6%
(8,
. Pancytopenia has multiple causes and
. Abdul Hamid reported a
the prognosis is dependent on the cause.
frequency of 48% in a series of
The frequency of these causes has been
pancytopenic patients in Yemen, he
reported in a limited number of studies
attributed this relatively high frequency
(8, 9)
to the high prevalence of malaria,
malignancies as a cause of pancytopenia
kalaazar and other infectious diseases
Among
studied
(8)
.In the present study hematological
.
was accounted for (51.7%) of cases.
patients
Acute leukemia was the most common
presentation varied according to the
cause
underlying
bleeding
responsible for 35% of cases. Acute
occurred most frequently among aplastic
lymphoblastic type constituted 20% of
anemia patients (60%), while none of
pancytopenic
megaloblastic
had
myelogenous leukemia formed 15% of
most
cases. In a study done by Jalaee and
leukaemia
Keihani in Tehran, acute leukemia was
condition,
thus
anemia
patients
bleeding.
Fever
occurred
frequently
among
acute
of
pancytopenia;
cases,
while
it
was
acute
133
the commonest cause of pancytopenia
reported a frequency of (18%) of
(11)
myelodysplastic syndrome
, similar results were reported from
(1)
, Iqbal et al
Sweden too, where neoplastic diseases
reported an incidence of (2.4%) in the
and radiation related marrow damage
same series reported a similar frequency
accounted for 32 % of cases while
for myelofibrosis
aplastic anemia accounted for 19% of
.
The second major causes of
(4, 13)
pancytopenia in this study were a plastic
acute leukemia was the second most
anemia and megaloblastic anemia, each
common cause of pancytopenia, In many
of them accounted for 16.7% of cases. A
Asian countries acute leukemia ranked
detailed history and thorough clinical
the 3rd or even the 4th cause of
examination did not help in establishing
pancytopenia,
cases
(12)
(16)
. In studies from India
being
next
to
the cause of marrow hypoplasia, one of
megaloblastic, Aplastic anemia
or
aplastic
patients
was
Fanconi
anemia
after
(1, 2, 3, 5, 6, 8, 10, 14, 15)
malaria
.
The relatively high frequency of
acute
leukaemia
as
a
cause
of
diagnosed
as
chromosomal
study. The relative frequency of aplastic
anaemia in this study is in agreement
(9,
pancytopenia in this study may be due to
with findings of many other workers
the fact that our locality has been the
10, 12, 17)
battle field for a series of wars since the
aplastic anaemia was the commonest
1960s and various weapons, including
cause of pancytopenia (1, 3, 15, 17, 18).
chemicals with potential leukaemogenic
Epidemiologically,
, however in many other studies
aplastic
effects have been used, another reason
anemia has a pattern of geographic
may be the blooming economy of
variation opposite to that of leukemia,
Kurdistan over the last decade may have
with higher frequency in the developing
reduced
world than in the industrialized West
the
relative
frequency
of
nutritional anemias.
(19)
.
Large prospective studies indicate an
The frequency of other blood
annual incidence of two new cases per
malignancies included were as follow;
million populations in Europe and Israel
myelodysplastic
20
hairy
cell
myelofibrosis
syndrome
leukemia
(1.7%).
(11.7%),
(3.3%)
Devi
and
et
al
. Its exact incidence in Kurdistan is not
known due to lack of population – based
studies. Studies from Thai land
(21)
and
134
China
(22)
showed the incidence to be
Megaloblastic anemia due to
about three folds that in the west. Its
vitamin B12 or folic acid deficiency is
exact etiology still not known but an
now a well –recognized and established
autoimmune
cause of pancytopenia
mechanism
has
been
(25)
. It can either
inferred from positive responses to non-
present as bicytopenia or pancytopenia,
transplant
or rarely with thrombocytopenia only
data
(3)
.
therapies
and
laboratory
Megaloblastic anemia in this
(26)
. The frequency of pancytopenia
series was as common as Aplastic
among
anaemia, it accounted for (16.7%) of
anaemia has range of 11% to 47%
cases. Similar results were reported from
almost all these studies, pancytopenia
Pakistan by Naeem et al and Memon et
was the main presentation and so was
al
(3, 15)
. In Yemen Abdul Hamid and
Shukry
showed
that
megaloblastic
(6)
in
the case in this study.
Conclusion
pancytopenia and accounted for (14.7%)
of cases
with
megaloblastic
anemia is the third commonest cause of
(8)
patients
We
concluded
that
physical
. Studies from India, had
examination and peripheral blood picture
shown megaloblastic anemia to be the
play an important role in planning
first
investigations in pancytopenic patients.
most
common
cause
of
pancytopenia and accounted for 44% to
72%
(9, 17)
. Increased incidence of
The
most
common
aplastic
anemia
perhaps
anaemia,
but
with
the
high
of
pancytopenia were acute Leukemia,
megaloblastic anemia in those studies
correlates
causes
and
rare
Megaloblastic
causes
like
prevalence of nutritional anemia due to
myelofibrosis, enteric fever, kala azar
religious and socio-economical reasons.
and secondary metastasis should also be
In Europe in a study on 213 cases of
kept in mind.
pancytopenia, carried out by Imbert et
al, (7.5%) of cases were due to
megaloblastic anemia
(23)
. Mosso et al,
showed the incidence of megaloblastic
anemia to be (7.41%) (24).
135
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Y, Vannasaeng S et al. Regional patterns
in the incidence of aplastic anemia in
14. Varma N and Dash S. A reappraisal
Thailand. Am J Hematol 1999;
of underlying pathology in adult patients
164- 8.
presenting
with pancytopenia.
61:
Trop
Geogr med 1992; 44(4): 322 – 327.
20. Young NS. Hematopoietic cell
destruction by immune Mechanisms In
15. Naeem Khan M ,Ayyub M, Nawaz
acquired
KH, Naeem N, Hussain T, Shujaat H et
Hematol 2000; 37: 3 - 14.
al.
Pancytopenia:
aplastic
anaemia.
Semin
clinicopathological
study of 30 cases at military Hospital,
21. Issaragrisil S, Chansung K, Kaufman
Rawalpindi. Pak J pathol 2001; 12 (2):
DW, Sirijirachai J, Thamprasit T, Young
37- 41.
NS et al. Aplastic anemia in rural
Thailand: it is association grain farming
16. Iqbal W, Hassan KH, Ikram N, Nur
and pesticide exposure. Am J Public
S. Aetiological break up in 208 cases of
Health 1997; 87: 1551- 1554.
pancytopenia. J Rawal Med Coll 2001; 5
(1): 7-10.
22. Yang C and Zhang X. Incidence
survey of aplastic anemia in China. Chin
17. Khunger JM, Arulselvi S, Sharma U,
Med Sci J 1991; 6: 203-207.
Ranga S, Talib VH. Pancytopenia – a
clinic haematological study of 200 cases.
23. Imbert M, Scoazec JY, Mdry JY,
Indian J Pathol Microbiol 2002; 45(3):
Jouzult H, Rochant H, Sultan C. Adult
375 – 379.
patients presenting with pancytopenia: A
137
reappraisal of underlying pathology and
megaloblastic
diagnostic procedures in 213 cases.
Indian Pediatr 2008; 39: 453-457.
Haematologic pathology 1989;
26.
3:
159-167.
Jan
Anaemia
in
children.
MA.Thrombocytopenia
in
children. J Postgrad Med Inst 2004; 18:
353-358.
24. Mosso M, Cassata A, Prieto S, Osay
L, salomon S, Carena J. Clinical impact
Correspondence to:
of pancytopenia in hospitalized patients.
Nawsherwan Sadiq Mohammad
Revista Medica universitaria 2008;
Pathology
4
(4): 17.
Department,
College
of
Medicine/ Hawler Medical University
25. Chandra J, Jain V, Narayan S,
Mob: 00964(0)7504384101
Sharma S, Singh V, Kapoor AK et al.
Folate and cobalamin deficiency in
138
‫‪Alan I.I, Nawsherwan S.M, Saran A. N.‬‬
‫‪A Clinical-Hematological Study of Pancytopenia‬‬
‫دراسة الخصائص السريرية والدموية من قلة كريات الدم الشاملة للمرضى الذين يراجعون‬
‫مستشفى نانه كه لي في مدينة أربيل‬
‫آالن إسحاق ايشو ‪ ،1‬نوشيروان صادق محمد‪, 2‬ساران عبد القادر نورالدين ‪3‬‬
‫‪/ MBChB 1‬ماجستير أمراض الدم ‪ /‬مستشفى أربيل التعليمي‬
‫‪/ FIBMS ،MBChB 2‬أمر اض الدم ‪ /‬قسم علم األمراض‪ ،‬كلية الطب ‪ /‬جامعة هولير الطبية ‪ /‬البريد اإللكتروني‪:‬‬
‫‪[email protected]‬‬
‫‪/ MBChB 3‬ماجستير أمراض الدم ‪ /‬مستشفى رزكاري التعليمي‬
‫الخلفية‪ :‬قلة الكريات الشاملة هو ثالوث الهيموغلوبين المنخفض‪ ،‬وقلة خاليا الدم البيضاء والصفائح الدموية‪ .‬على‬
‫الرغم من أنها مشكلة سريرية شائعة مع وجود التشخيص التفريقي الواسع‪ ،‬هناك مناقشة قليلة نسبيا لهذه الحاالت في‬
‫وأمراض‬
‫الباطني‬
‫للطب‬
‫الرئيسية‬
‫الكتب‬
‫األهداف‪ :‬تهدف هذه الدراسة إلى تحديد المسببات والتعريف السريري للمرضى الذين يعانون من قلة الكريات الشاملة‬
‫لي‪.‬‬
‫كه‬
‫نانه‬
‫لمستشفى‬
‫حضروا‬
‫الذين‬
‫المواد والطرق‪ :‬خالل فترة ‪ 6‬أشهر‪ ،‬حضر ‪ 66‬مريضا يعانون من قلة الكريات الشاملة الى مستشفى نانه كه لي ‪،‬‬
‫تراوحت أعمارهم بين ‪ 11-1‬سنة‪ .‬تم اختبار مجموعة السيطرة من ‪ 06‬شخصا من االصحاء المتطابقين بالعمرو تم‬
‫اخذ صورة الدم ا لكاملة وتعداد الشبكيات‪ .‬وقد تم تسجيل تاريخ المرض‪ ،‬والفحص السريري ومعلومات فحص الدم ‪.‬‬
‫وتضمن الملف الدموي الهيموغلوبين‪ ،‬وعدد وتفاصيل الكريات البيض‪ ،‬عدد الصفائح الدموية‪ ،‬عد الخاليا الشبكية‪،‬‬
‫الدم المحيطي ومسحات نخاع جنبا إلى جنب مع خزعة نخاع‪ .‬تم استبعاد مرضى السرطان على العالج الكيميائي مع‬
‫قلة الكريات الشاملة‪ .‬وقد عرفت قلة الكريات الشاملة كاالتي ‪ :‬الهيموجلوبين أقل من ‪ 16‬غم‪/‬د ل‪ ،‬كرات الدم البيضاء‬
‫أقل من ‪/169 * 4‬لتر وعدد الصفيحات أقل من ‪ / 169* 106‬لتروكانت متوسط تركيز الهيموغلوبين ‪ ،‬وعدد كرات‬
‫الدم البيضاء و الصفائح الدموية في المجموعة المدروسة أقل بكثير مما كانت عليه في المجموعة الضابطة‪.‬‬
‫النتائج‪ : .‬كانت األورام الخبيثة الدموية السبب األكثر شيوعا لقلة الكريات الشاملة وتمثل (‪ ،)٪01.5‬وشملت‪:‬‬
‫سرطان الدم الحاد (‪ ،)٪30‬ومتالزمة اعتالل نخاع العظم (‪ ،)٪11.5‬سرطان الدم الشعيري (‪ )٪3.3‬وتليف نخاع‬
‫العظم (‪ .)٪1.5‬فقر الدم الالتنسجي وفقر الدم الوبيل كل منها تمثل (‪ ،)٪16.5‬وفرط نشاط الطحال مسؤولة عن‬
‫(‪ .)٪ 16‬وتضمنت أسباب أخرى أقل شيوعا مثل حمى المعوية‪ ،‬والحمى السوداء واالنتشار الثانوي للسرطان كل‬
‫منها تمثل (‪ .)٪1.5‬كان الشحوب موجود في كل حالة‪ .‬كانت الحمى موجودة في (‪ )٪63.3‬و مظاهر النزيف في‬
‫المراجعة‪.‬‬
‫وقت‬
‫(‪)٪20‬‬
‫االستنتاجات‪ :‬كانت األسباب األكثر شيوعا لقلة الكريات الشاملة هي سرطان الدم الحاد وفقر الدم الالتنسجي وفقر‬
‫الدم الوبيل‪ ،‬ولكن األسباب النادرة مثل تليف نخاع العظم ‪ ،‬حمى المعوية‪ ،‬الحمى السوداء واالنتشار الثانوي للسرطان‬
‫االعتبار‪.‬‬
‫في‬
‫يوضع‬
‫أن‬
‫أيضا‬
‫ينبغي‬
‫كلمات البحث‪ :‬قلة الكريات الشاملة‪ ،‬نخاع العظام‪ ،‬أمراض الدم الخبيثة‪.‬‬
‫‪139‬‬
Table 1: Statistical summary of the routine haematological parameters of studied
patients:
Haematological parameters
Mean ± SD
Patients (n = 60)
Hb ( g/dl)
8.14 ±1.78
WBC×109/L
2.19 ± 0.91
Platelets×109/L
Reticulocyte count (%)
55.35 ± 39.82
0.82 ±0.87
MCV (fl)
90.12 ± 12.5
MCH(pg)
31.1 ±4.98
MCHC( g/dl)
34.7 ± 2.51
140
Table 2: Causes of pancytopenia
Causes of pancytopenia
Frequency
Percent
Malignant blood diseases
31
51.7
Aplastic anaemia
10
16.7
Megaloblastic anaemia
10
16.7
Hypersplenism
6
10
Enteric fever
1
1.7
Kalazar
1
1.7
Secondary metastasis
1
1.7
Total
60
100
Table 3: Malignant blood diseases causing pancytopenia:
Malignant blood diseases
Frequency
Percent from(60) studied
patients
Acute leukaemia
21 (67.7%)
35
7 (22.6%)
11.7
Hairy cell leukaemia
2 (6.5%)
3.3
Myelofibrosis
1 (3.22%)
1.7
Total
31(100%)
51.7
141
Table 4: comparison of hematological parameters between the three major causes
of pancytopenia:
Age
HB ( g/dl)
WBC×109/L
9
Platelets×10 /L
Reticulocyte Count (%)
Diagnosis
No
A. Acute leukemia
21
18.14±17.4
B. Aplastic anemia
10
26±21.20
C. Megaloblastic anemia
10
55.8±14.85
A. Acute leukemia
21
8.21±1.67
B. Aplastic anemia
10
6.85±1.57
10
8.15± 1.92
A. Acute leukemia
21
2.1 ± 0.9
B. Aplastic anemia
10
2 ± 0.89
10
2.89 ± 0.54
A. Acute leukemia
21
50 ± 34.3
B. Aplastic anemia
10
22.1± 17.6
10
92.1±41.32
A. Acute leukemia
21
0.74± 0.62
B. Aplastic anemia
10
0.71± 0.28
Mean ±SD
P-value
< 0.001
Significance
AXC
BXC
0.11
0.04
AXC
< 0.001
AXC
0.97
0.71±0.30
10
A. Acute leukaemia
21
78.18±8.73
B. Aplastic anemia
10
29.5 ± 6.4
10
90±4.08
A. Acute leukaemia
21
62.42±23.8
Bone marrow
B. Aplastic anemia
10
2.7±0.94
Blast cell (%)
C. Megaloblastic
10
2.5±0.97
Bone marrow
cellularity
AXB
< 0.001
AXC
BXC
< 0.001
AXB
AXC
anemia
142
‫المجلة العراقية ألمراض الدم‬
‫مجلــــة علميــــــة محكمـــــــة تصــــدر مرتيــــن في السنــــة عــــــــــن‬
‫المركز الوطني لبحوث وعالج امراض الدم‪ -‬الجامعة المستنصرية‪ -‬بغداد‪ -‬العراق‬
‫المجلد ‪ 5‬العدد‪2‬‬
‫ايار ‪1026‬‬
‫رئيس التحرير‬
‫مدير التحرير‬
‫أ‪.‬د عالء فاضل علوان‬
‫أ‪.‬د علي محمد جواد المظفر‬
‫سكرتير المجلة‬
‫د‪ .‬نضال كريم الرحال‬
‫هيئة التحرير‬
‫الهيئة االستشارية‬
‫(جامعة النهرين)‬
‫أ‪.‬د‪.‬نصير عالوي(جامعة دهوك)‬
‫أ‪.‬د‪ .‬رعد جابرموسى‬
‫أ‪.‬د‪.‬خالد نافع(جامعة الموصل)‬
‫أ‪.‬د‪ .‬بان عباس‬
‫أ‪.‬د‪ .‬علي مسلم(امريكا)‬
‫ا‪.‬د سلمى عباس الحداد(جامعة بغداد)‬
‫أ‪.‬د‪ .‬احمد ابراهيم(لبنان)‬
‫ا‪.‬م‪.‬د عالء الدين مظفر(الجامعة المستنصرية)‬
‫أ‪.‬د‪ .‬انور شيخه(جامعة السليمانية)‬
‫ا‪.‬م‪.‬د عالءالدين سهام ناجي( جامعة بغداد)‬
‫(جامعة النهرين)‬
‫ا‪.‬د‪ .‬وسيم فاضل التميمي(جامعة النهرين)‬
‫أ‪.‬د‪ .‬ميعاد كاظم(جامعة البصرة)‬
‫أ‪.‬د‪ .‬صبح المدلل(جامعة النهرين)‬
‫أ‪.‬م‪.‬د نبيل سلمان(مصر)‬
‫أ‪.‬م‪.‬د عالء صادق(جامعة بابل)‬
‫أ‪.‬م‪.‬د احمد خضير(جامعة هولير)‬
‫أ‪.‬م‪.‬د‪ .‬رحيم مهدي(جامعة الكوفة)‬
‫د‪ .‬جعفر الغبان (م‪.‬الطفل المركزي)‬
‫أ‪.‬م‪.‬د‪ .‬اديب عباس(الجامعة المستنصرية)‬
‫أ‪.‬م‪.‬د‪.‬مازن فيصل(جامعة بغداد)‬
‫أ‪.‬م‪.‬د هيثم الربيعي(جامعة بغداد)‬
‫د‪ .‬فاتن ال ياسين(جامعة بغداد)‬
‫د‪ .‬ابراهيم خليل ابراهيم (م‪.‬الكاظمية )‬
‫د‪ .‬بسام فرنسيس(م‪.‬بغداد التعليمي)‬
‫د‪.‬اسعد عبد االمير ( م‪ .‬البصرة التعليمي)‬
‫د‪ .‬عبد المجيد علوان(م‪.‬اليرموك التعليمي)‬
‫صدر العدد االول في ‪1122‬‬
‫اول رئيس تحرير د‪.‬نبيل سلمان مراد‬
‫اول مدير تحرير د‪.‬اديب الشامي‬

iraqi journal of hematology vol.5 issue 1 2016

Transcription

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