Iraqi Journal of Hematology

Abstract:
BACKGROUND: Syndecan‑1 (CD138) is a member of the transmembrane proteoglycans family that is expressed in various normal and malignant tissues. It attracted the attention because of its possible prognostic role when expressed in different tumors as well as its role as a target for therapy by the monoclonal antibody indatuximab coupled with other cytotoxic agents. In acute myeloid leukemia (AML), syndecan‑1 was found to be significantly increased either inside leukocytes or as a soluble form in the plasma and it was correlated with overall survival of AML patients and with more bleeding manifestations and impaired platelet function.
AIMS: The aims of this study were to assess the level of soluble syndecan‑1 (or CD 138) in adult patients with de novo AML compared to the control group and to explore any possible correlation between the level of syndecan‑1 with hematological parameters and response to remission induction therapy.
PATIENTS AND METHODS: Cross‑sectional study recruited 60 newly diagnosed adult AML patients. Moreover, 25 healthy individuals were included as the control group. The peripheral blood and bone marrow smears were examined at presentation for establishing the diagnosis and after remission induction for assessing the treatment response. Plasma syndecan‑1 assay was done by sandwich enzyme‑linked immunosorbent assay, which was done to patients at time of diagnosis.
RESULTS: Plasma syndecan‑1 (SDC‑1) level of AML patients at presentation was much higher than that in the control group (P < 0.001); there was also a statistically significant difference in plasma level of syndecan‑1 between male and female patients (P = 0.002). There was no significant difference for plasma (SDC‑1) level between different AML French American British (FAB) subtypes; however, the highest level was seen among patients with the M3 subtype. No significant difference for plasma (SDC‑1) level was seen between the patients who achieved remission status and patients who failed to achieve remission after chemotherapy and also between patients alive and deceased after 6 months of follow‑up. Insignificant correlations were demonstrated between soluble (SDC‑1) and the presenting complete blood count (CBC) parameters.
CONCLUSIONS: Although the high level of plasma syndecan‑1 was demonstrated in patients with AML compared to the control group, there was no significant difference with respect to age, FAB subtype, and type of response to treatment nor with the patient outcome, and also no significant association was established with any of the hematological parameters.

Abstract:
BACKGROUND: Compared to other blood cells, adult red blood cells have a higher concentration of microRNAs (miRNAs). The effectiveness of preserved blood cells following transfusion is affected by a variety of factors, like changes in miRNA levels. One day, these small RNAs might help determine the efficacy and safety of blood products.
AIMS: This study sought to identify the miRNA present in both fresh blood and stored blood because there is growing evidence that these cells are enriched with miRNAs.
MATERIALS AND METHODS: Blood samples were taken from three healthy donors to detect the expression of miRNAs using illumina platform for RNA sequencing. Total RNA was isolated from stored units at 0, 14, 21, and 28 days, respectively. Bioinformatics analysis has been carried out to analyze the miRNAs.
RESULTS: The majority of miRNA expression was decreased in time‑dependent manner, particularly after day 14 of packed blood cells (PBCs) storage such as hsa‑miR‑20a‑5p, hsa‑miR‑17‑5p, and hsa‑miR‑423‑3p. While other miRNAs such as hsa‑miR‑320a‑3p, hsa‑miR‑186‑5p, and hsa‑miR‑486‑5p, showed a significant re‑upregulated after day 21.
CONCLUSION: In summary, the PBCs at days 14 and 21 had the lowest levels of miRNAs, which may indicate less of a relationship with storage lesions. However, older PBCs displayed significant levels of miRNAs, which could indicate storage lesions or cause a number of clinical issues for the recipients.

Abstract:
BACKGROUND: Chronic myelogenous leukemia is a hematological disorder of stem cells resulting from uncontrolled and unregulated growth of myeloid cells in the bone marrow. Since the introduction of tyrosine kinase inhibitors (TKIs), therapy has dramatically improved survival in these patients. TKIs treatment targeting BCR‑ABL significantly improves the prognosis of patients with chronic myelogenous leukemia. To date, the validity of scoring systems is insufficient for predicting prognosis, and there are few studies of scoring systems for predicting treatment response and clinical efficacy of TKIs.
OBJECTIVES: The objective of this study was to evaluate the ability of the red blood cell distribution width (RDW) to predict treatment response in chronic myeloid leukemia‑chronic phase (CP) patients treated with first‑generation TKI.
PATIENTS AND METHODS: A prospective and retroprospective cohort study was conducted on chronic myeloid leukemia‑CP patients treated with first‑generation TKI at Iraqi Hematological Centers. The collection period was from December 2020 to November 2021. Patients were treated with first‑generation TKIs as initial therapy and were followed up to assess the response by polymerase chain reaction (PCR). The assessment of RDW was done at baseline and then at 3, 6, 12, and 18 months after initiation of therapy.
RESULTS: There were 150 patients included in this study. The mean age of patients was 43.7 ± 14 years (range: 18–84 years). Males were representing 48.6% and females 51.3%. The classification of baseline RDW showed that the majority of patients (53%) had high RDW. The RDW showed significant change over time, in which, it was significantly decreasing over time (P < 0.05). Association between PCR over time and baseline RDW category showed that the high baseline RDW was associated with higher mean PCR at 3, 6, 12, and 18 months (P < 0.05). The correlation between RDW at baseline and PCR at 3, 6, 12, and 18 months showed that there was a significant positive weak correlation between baseline RDW and PCR at 6, 12, and 18 months. The association between baseline RDW and the response showed that high baseline RDW was associated with higher failure rate at 6 and 12 months (P < 0.05).
CONCLUSION: RDW could be used in the prediction of response to treatment. Furthermore, high RDW showed significant association with high disease activity score, high white blood cell count, and lower hemoglobin, in addition to association and correlation with PCR level.

Abstract:
BACKGROUND: Beta‑thalassemia, a hereditary blood disease transmitted through families, has become increasingly relevant with rising life expectancies, leading to bone disease being a significant cause of morbidity. Among the symptoms observed in these patients, bone pain and back pain are frequently reported. Vitamin D is believed to play a crucial role in reducing these symptoms.
AIM: The objective of this study was to assess the Vitamin D levels in thalassemic patients and investigate potential correlations with other factors.
PATIENTS AND METHODS: A cross‑sectional study was conducted, involving a random selection of 48 patients with beta‑thalassemia (major and intermediate types) aged 7 years and above. The patients were registered at the Hereditary Blood Disease Center in Wasit province, located in the South of Iraq, during the period from January to May 2022. Demographic data, including age, sex, address, diagnosis, type of chelation therapy, and frequency of blood transfusions, were collected from patients’ files. Biochemical data, such as mean hemoglobin, mean serum ferritin, mean serum calcium, and Vitamin D levels at the time of the study, were also recorded. Vitamin D levels below 30 ng/ml were considered low level or deficiency, whereas 30 ng/ml and above were considered normal, as indicated by the kit manufacturer. Furthermore, the height, weight, and body mass index were evaluated in the studied patients with their written consent. SPSS version (23) was employed for data management and statistical analysis, utilizing a significant P = 0.05 and the Pearson’s correlation.
RESULTS: The study revealed that 42 patients (87.5%) had low Vitamin D levels (below 30 ng/ml). The mean Vitamin D level was 18.23 ng/ml, with a maximum reading of 45 ng/ml. It was observed that Vitamin D deficiency was more prevalent in younger patients and those with higher ferritin levels, although the differences were not statistically significant.
CONCLUSION: Vitamin D deficiency is common in patients with B‑thalassemia, as indicated by this study.

Abstract:
BACKGROUND: Hemophilia is an inherited bleeding disorder that could cause many complications, one of which is hemarthrosis. Neutrophils are the predominant immune cells that infiltrate joints after hemorrhage. Tissue injury is often accompanied by the production of neutrophil extracellular traps (NETs), which are DNA constructs containing attached granular enzymes.
AIMS OF STUDY: The aim of this study was to identify the presence of neutrophil extracellular traps including the neutrophil elastase (NE) and myeloperoxidase (MPO), in patients with hemophilia A presented with hemarthrosis.
SUBJECTS AND METHODS: During a period of 8 months from November 2022 to June 2023, 50 persons were recruited cross‑sectional study was conducted. In the current study, a sample of 25 individuals with hemophilia A presenting with hemarthrosis were included. Additionally, a control group of 25 unrelated, almost healthy persons,matched in terms of age and sex were also included. NE and MPO levels in blood were measured by flow cytometry technique.
RESULTS: The level of MPO and NE in the blood was significantly higher in hemophilia A patients than controls. In the results of hemophilia A patients, the mean and standard deviation of MPO were 3253.36 +_1865.48, while for NE it was 5229.08+_2667.43. These values were found to be statistically significant P<0.05 when compared to the control group. In the control group, the mean and standard deviation of MPO were 2285.48+_811.89, and for NE, it was 3816.92+_1890.45.
CONCLUSIONS: Patients with hemarthrosis had a considerably increase level of NETs in their blood than healthy individuals, and these findings indicate a function of NETs in the pathology of hemophilia A with hemarthrosis.

Abstract:
BACKGROUND: Due to their impact on crucial steps in hematopoiesis, long noncoding RNAs (lncRNAs) deregulation potentially accelerates the growth and development of blood cancers like acute myeloid leukemia (AML). The study aimed to look into different expression patterns, prognostic value, and clinical importance of lncRNA small nucleolar RNA host gene 5 (SNHG5) and promoter of cyclin‑dependent kinase inhibitor 1A antisense DNA damage‑activated RNA (PANDAR) genes in Egyptian adult patients with AML.
SUBJECTS AND METHODS: The case–control study was conducted between 2019 and 2022 at the Clinical Pathology Department at the National Cancer Institute, Cairo University, Egypt. The study involved 80 recently diagnosed patients with AML and 20 healthy controls. Real‑time quantitative reverse transcription polymerase chain reaction was used to assess the levels of expression of SNHG5 and PANDAR genes.
RESULTS: In comparison to healthy controls, there was a significantly higher SNHG5 gene expression (P = 0.026) and PANDAR expression (P < 0.001) in patients’ bone marrow samples. The study of the correlations revealed a significant positive association between SNHG5 and PANDAR genes in AML patients. The overall survival (OS) was significantly better in the low SNHG5 gene expression group than in the high SNHG5 gene expression group. No significant difference was detected regarding the disease‑free survival (DFS) between patients with low expression and high expression of the SNHG5 gene. No significant variation between high PANDAR gene and low PANDAR gene expression regarding OS and DFS.
CONCLUSION: SNHG5 and PANDAR may have a pathogenic role in AML, and their overexpression might be considered a marker for diagnosis in AML patients in Egypt. SNHG5 expression can be used as a predictor for OS, while PANDAR expression cannot be used as a predictor for OS or DFS in patients.

Abstract:
BACKGROUND: Mutations in the FLT3 gene are very common in acute myeloid leukemia (AML). These mutations are linked to a high chance of the disease relapse and decrease overall survival. This study aimed to investigate this mutation in AML cases and to correlate it with the clinicopathological presentation and their response to induction therapy.
OBJECTIVES: This study aimed to investigate this mutation in AML cases and to correlate it with the clinicopathological presentation and their response to induction therapy.
METHODS: This study was done on 63 AML cases; for each patient, the clinical presentation and the hematological lab parameters were recorded. The results of FLT3 internal tandem duplication (ITD) mutation were recorded and the mutation was detected by conventional polymerase chain reaction technology. Postinduction assessment was recorded for each patient.
RESULTS: The mean age of the studied group was 36.06 (22.42), with a male to female ratio of 1:1.6. Out of 63 AML patients, 16 (25.4%) had FLT3‑ITD mutation. The highest incidence of the mutation was found among the age group of 10–19 years (40%). The highest incidence of FLT3 mutation was among M3 (45.5%). The blast count was significantly higher in patients with than without the mutation (P = 0.04). The remission rate was significantly lower in FLT3 AML patients than in those lacking the mutation (P = 0.45).
CONCLUSION: FLT3‑ITD mutation was common in our AML patients. This mutation was associated with significantly higher counts of blast and poorer response to induction therapy; thus, it is considered one of the poor prognostic factors.

Abstract:
BACKGROUND: Since the beginning of the coronavirus disease 2019 (COVID‑19) pandemic, reports of false‑positive serological test results were reported in COVID‑19 patients. Typhidot IgM test is reported in a few studies to give false‑positive results in various viral illnesses in the past. The aim of this study was to estimate the typhidot IgM positivity rate in reverse transcription‑polymerase chain reaction (RT‑PCR)‑confirmed COVID‑19 patients.
MATERIALS AND METHODS: The present study was a cross‑sectional study conducted at a tertiary care hospital. All symptomatic patients having fever that were admitted between April 1, 2021, and July 15, 2021, with a confirmed RT‑PCR‑positive result for severe acute respiratory syndrome coronavirus‑2 (SARS‑CoV‑2) were included in the study. Serological testing was done by typhoid IgM/IgG rapid diagnostic test for all SARS‑CoV‑2 RT‑PCR‑positive patients. The primary outcome studied was to estimate the typhidot IgM positivity rate among RT‑PCR‑confirmed COVID‑19 patients. The secondary outcome studied was to determine the correlation between SARS‑CoV‑2 RT PCR cycle threshold (CT) value and typhidot‑positive result.
RESULTS: Three hundred and five (17.99%) out of 1695 samples of confirmed COVID‑19 patients were positive for typhoid serology by typhidot IgM test. However, upon performing Point‑Biserial correlation analysis (P = 0.832, r = 0.021), no correlation was seen between RT‑PCR CT value and typhidot result.
CONCLUSIONS: Typhidot test is a nonspecific diagnostic test for typhoid fever which can be false positive in COVID‑19 patients. Hence, physicians should take this into consideration to avoid misdiagnosis and delay in accurate treatment of acute febrile illness cases, especially in the present scenario of COVID‑19 endemicity.

Abstract:
BACKGROUND: Patients with hemoglobinopathies are considered as immunocompromised; however, it is unclear if they are more susceptible to COVID‑19 infection and experience a more severe illness course.
AIMS OF STUDY: The aims of this study were to evaluate the clinical presentation and severity of COVID‑19 among pediatric patients with hemoglobinopathies, assess risk factors, and outcome among studied patients.
PATIENTS AND METHODS: An analytical, cross‑sectional study has been carried out on children and adolescents with hemoglobinopathies, for the period from the first of May 2021 to September 2022. In addition to patient’s data and thorough physical examination, patients were followed concerning the course, complications, and disease outcome. Investigations included complete blood count, inflammatory markers, liver, and renal function tests.
RESULTS: Out of 42 patients with hemoglobinopathies and COVID‑19, the majority of patients 35 (83.3%) gave a history of COVID‑19 exposure, with a median of 5 days for the presentation since exposure and 23 (54.8%) needed hospitalization. All studied patients had fever, followed by cough in 36 (85.7%) and shortness of breath (42.9%). No death was reported in studied patients. The lymphocyte count was significantly lower and C‑reactive protein and D‑dimer levels were significantly higher in sickle cell disease (SCD) patients with COVID‑19 as compared to thalassemia patients, P < 0.05. Twenty‑two patients (52.4%) had mild COVID‑19 disease, 12 (28.6%) moderate, and 8 (19%) with severe disease. Regression analysis revealed that acute chest syndrome (ACS) as COVID‑19 infection presentation, high white blood cells count, and elevated total serum bilirubin were significant variables associated with severe COVID‑19 infection, P < 0.05.
CONCLUSION: The clinical course of hemoglobinopathy patients with COVID‑19 infection is similar to that in the general population and no death was reported among studied patients. However, clinicians treating patients with SCD need to be aware of COVID‑19 infection when diagnosing ACS.

Abstract:
BACKGROUND: Chronic myeloid leukemia (CML) has been well recognized as an exemplary instance of a malignant disease characterized by a distinctive molecular occurrence, namely the presence of the breakpoint cluster region (BCR)‑c‑ABL oncogene 1 (ABL1) oncogene. The Philadelphia chromosome gives rise to an anomalous fusion gene characterized by atypical kinase activity, resulting in the accumulation of reactive oxygen species and genetic instability that holds significance in the advancement of diseases.
OBJECTIVE: The objective of this study was to investigate the detection rate of BCR‑ABL1 polymorphism and BCR protein level in a group of Iraqi patients with CML.
MATERIALS AND METHODS: This study has been carried out on 150 specimens, 120 patients subjected to CML included 20 patients diagnosed as newly diagnosis CML and 100 patients treated with CML. In addition to 30 apparently healthy persons as a control group (normal persons) from the National Center of Hematology/Mustansiryiah University/Baghdad, 65 out of 100 patients on imatinib while 35 nonimatinib (nilotinib and bosutinib). Fresh whole blood and serum were obtained from all patients and controls. We used total DNA genomic extraction extracted from ethylenediaminetetraacetic acid blood for genetic detection of Bcr/Abl Genes Polymorphism by sequencing technique in patients with CML and apparently control groups and used serum for biochemical tests include urea, lactate dehydrogenase (LDH), aspartate transaminase (AST), alanine transaminase (ALT), and creatinine using biochemicals methods (colorimetric and kinetic), respectively, as well as detection BCR protein level using sandwich enzyme‑linked immunosorbent assays technique.
RESULTS: According to age and sex, the patients’ groups were matching with the control group. Regarding the biochemical parameters (urea creatinine, ALT, AST, and LDH) serum level, there are no significant differences among new diagnosis CML, patients respond to treatments and failure group except in serum level of creatinine between new diagnosis CML group and failure group, there are significant differences (P = 0.01). The present results showed that DNA polymorphism distribution was according to C\C; G\C; A\T; and A\A were 32%, 26%, 18%, and 24%, respectively, in patients with CML and 28%; 20%;12%; and 40%, respectively, in the control group. There are significant statistical differences (P < 0.05) between different groups according to the genotyping of BCR\ABL, the results obtained from the sequenced 429 bp fragments, and the detailed positions of the observed variations are described in the NCBI reference sequences (rs766724113). The samples were submitted in NCBI, and the accession number of nucleotide sequences of BCR\ABL as new recording: LC 775148, LC 775149, and LC 775150, while regarding with BCR protein, there are significant differences in level between new diagnosis CML and CML on treatment and control groups, P < 0.001 for each comparison while there are no significant differences between treated group and control group (P = 0.729).
CONCLUSION: The present results indicate that BCR‑ABL1 polymorphism and BCR protein level in a group of Iraqi patients
with CML may play a role in the tumor biology of the examined subset of CML and may contributed to their development.

Abstract:
BACKGROUND: As in other malignancies, different subsets of natural killer (NK) cells play a crucial role in the recognition and lysing of malignant cells in chronic myeloid leukemia (CML).
OBJECTIVES: This study aims to identify two subsets of NK, cytotoxic (cluster of differentiation [CD] 16+bright) and cytokine‑producing NK (CD56+bright) in newly diagnosed CML patients.
MATERIALS AND METHODS: This study is conducted on 20 newly diagnosed Iraqi patients (12 males and 8 females) with CML, in chronic phase, at the age range of 17–55 years. Along with patients, 20 healthy subjects (with matched age and gender) were enrolled to act as a control group. To identify NK cells and their subsets in peripheral blood samples, the expression of CD45, CD3, CD56, and CD16 markers was evaluated by flow cytometry technique. Furthermore, the serum level of interferon gamma (IFN‑γ) and interleukin (IL)‑18 was determined by the enzyme‑linked immunosorbent assay technique.
RESULTS: The age of patients at the diagnosis of disease is (35.6 ± 12.2 years) and the male: female ratio was 1.5:1. The serum level of IL‑18 in newly diagnosed CML patients (30.3 ± 6.5 pg/mL) was significantly (P < 0.0001) higher than those in control group (18.3 ± 7.8 pg/mL), while the serum levels of IFN‑γ in newly diagnosed patients are significantly (P = 0.006) dropped down to (89.1 ± 7.2 pg/mL from that in control group (109.4 ± 30.3 pg/mL). The percentage of NK cells in newly diagnosed CML patients is significantly lower than in control group. There is a significant elevation in the cytotoxic NK cells (CD16+bright) subset, and a significant decrease in the cytokine‑producing NK subset (CD56+bright) in newly diagnosed patients when compared to those in control group.
CONCLUSION: Although there is an elevation in the percentage of cytotoxic NK cells (CD16+bright) subset of CML patients at the first diagnosis, these cells are not able to recognize and attack malignant cells, which may be due to low expression of their activating receptors and needs more investigation. Furthermore, present results found a low percentage of cytokine‑producing NK cells (CD56+bright) and a low level of IFN‑γ in CML patients, although there is an elevation in IL‑18, which indicates that IL‑18 may be not the main stimulator to these cells, so activation pathway of this subset of NK cells needs further investigation.

Abstract:
A 23‑year‑old male was misdiagnosed as a case of tubercular lymphadenitis based on fever with B‑symptoms and finding of epithelioid granuloma on fine‑needle aspiration of mesenteric lymph node and was started on antitubercular treatment from an outside hospital. Since the patient had progression of symptoms, we re‑evaluated the case. Contrast‑enhanced computed tomography showed multiple conglomerated necrotic cervical, peritoneal lymph nodes, hepatosplenomegaly, and multiple mixed sclerotic lytic lesions in multiple vertebral bodies and pelvis. An excision lymph node biopsy was suggestive of a nodular sclerosis variant of Hodgkin’s lymphoma. A bone marrow study was performed subsequent to new‑onset bicytopenia. Bone marrow aspiration was dry and bone marrow biopsy showed myelofibrosis. Thus, a diagnosis of myelofibrosis secondary to Hodgkin’s lymphoma was made.

Abstract:
Waldenstrom macroglobulinemia (WM) is a rare, chronic, and indolent B‑cell lymphoproliferative disorder characterized by bone marrow infiltration by small lymphocytes, lymphoplasmacytoid cells, and plasma cells along with the presence of a detectable monoclonal immunoglobulin M. It represents 1%–2% of hematological malignancies with an overall incidence of 3–4 cases/million persons/year. Some deletions are associated with a more aggressive IgM gammopathy and have a high probability of symptomatic transformation. 6q deletion, the most common cytogenetic abnormality, which is present in 42% of cases whereas 11q deletion is rare in WM and is present in only 8% of cases. We are presenting a case of a 70‑year‑old male patient diagnosed as WM with 11q deletion.

A 68-year-old man presented with a low-grade fever for one month. He had loss of appetite and had lost 6 kilograms of weight in the last two months. He was evaluated and found to have miliary tuberculosis with pancytopenia. The bone marrow revealed Gelatinous transformation of bone marrow and there was no evidence of other causes of pancytopenia like histiocytic hyperplasia, maturation arrest, or infiltration of the bone marrow. The pancytopenia improved with anti-tubercular treatment showing the reversible nature of the disease. To conclude, multiple mechanisms can result in pancytopenia in tuberculosis. A bone marrow study can reveal most of them including rare causes like GTBM.

Abstract:
Practically, all major organ systems can be impacted by an immune‑mediated fibro‑inflammatory condition known as immunoglobulin G4‑related disease (IgG4‑RD). Even though it is not unusual, the level of orbital involvement in IgG4‑RD can change depending on where the lymphoplasmacytic infiltrate is located. We address a case of IgG4‑RD in this study who presented with large bilateral upper and lower eyelids swelling, mediastinal lymphadenopathy, and elevated serum IgG4. It was necessary to do a histopathology examination to confirm the diagnosis of the IgG4‑RD and rule out any possible mimicking hematological conditions. In conclusion, this case report emphasizes the value of clinical symptoms and imaging in reducing the number of potential diagnoses, although biopsy remains a gold standard to confirm the diagnosis of IgG4‑RD.

A 55‑year‑old homemaker presented with low‑grade fever, fatigue, and loss of weight for 2 months. She had hepatosplenomegaly, mediastinal lymphadenopathy, cytopenias, hypercalcemia with normal parathormone, and noncaseating granulomas in bone marrow and lymph node biopsy. The patient was diagnosed to have sarcoidosis with bone marrow involvement (histopathology showing noncaseating granuloma and high serum angiotensin‑converting enzyme after ruling out other causes of granulomatous disorders by appropriate tests). She was managed with prednisolone 20 mg daily which was reduced and stopped after 3 months. On follow‑up, she was asymptomatic and her blood counts were normal. Diagnosis of sarcoidosis should be considered always after ruling out other causes since it can mimic lymphoproliferative disorders and granulomatous infections. The initial presentation of sarcoidosis with bicytopenia due to bone marrow granulomas is extremely rare and physicians should have awareness of such atypical