Iraqi Journal of Hematology

Abstract:
BACKGROUND: Complete blood count and cell counter generated red blood cell (RBC) parameters
help in morphological typing of anemia. Still the importance of microscopic examination of peripheral
blood smears (PBSs) cannot be excluded to interpret the cause of anemia.
AIMS AND OBJECTIVES: The present study was done to diagnose the type of anemia by examination
of PBS and automated cell counter generated parameters and to compare the findings between
these two methods.
MATERIALS AND METHODS: During the 6‑months study, 9981 anemic blood samples were
evaluated. PBS findings and cell counter generated RBC parameters and histograms were evaluated
and compared.
RESULTS: Among 9941 samples, microcytic hypochromic anemia consists of the majority
of cases (5048, 50.47%), followed by normocytic normochromic (2187, 21.97%), dimorphic
(1297, 12.99%), and lastly, hemolytic anemia (722, 7.24%). Compared with RBC parameters and
peripheral smear findings, dimorphic and hemolytic anemia showed significant difference (P < 0.0001).
When compared with RBC histogram, 4747 (47.56%) cases showed left shift, 820 (8.21%) cases
showed right shift, and 2278 (22.82%) cases showed normal bell‑shaped curve suggesting microcytic,
macrocytic, and normocytic normochromic anemia, respectively. 635 (6.90%) and 1447 (14.50%)
number of cases showed bimodal and broad‑base histogram suggesting dimorphic and hemolytic
anemia, respectively.
CONCLUSION: PBS examination along with RBC histogram study can be able to categorize the
type of anemia in the majority of cases. Each method should be used as complementary to each
other that increases diagnostic accuracy.

Abstract:
BACKGROUND: Global pandemic COVID‑19 is an acute respiratory illness with a high rate of
hospitalization and death rate. Red cell distribution width coefficient of variation (RDW‑CV), a routine
component of complete blood count (CBC) automatically generated by most hematology analyzers
is a useful predictor of clinical outcomes in critically ill patients and in those with infection and sepsis.
RDW will provide information for early risk stratification of COVID‑19 patients, thereby enabling timely
intervention for reducing morbidity and mortality. In such a massive pandemic, early stratification of
cases based on routinely available biomarkers can be of great help inefficient utilization of critical
care and laboratory assets.
MATERIALS AND METHODS: We retrospectively studied the significance and correlation of
RDW (CV) (admission) with the severity of clinical illness in 800 confirmed cases of COVID‑19
between August 2020 and October 2020 at our hospital. Demographic and clinical details were
obtained from medical records; data pertaining to CBC were retrieved through electronic records of
our fully automated hematology analyzer (NihonKoden 5 part auto analyzer Model‑MEK– 7300K).
Statistical workup was done and results were analyzed.
RESULTS: Of 800 patients, 60% were male. RDW (CV) >14.5 (elevated) seen in 52% males and
47% females. Elevated RDW was noted in 43.6% (300/688) nonsevere illnesses (mild and moderate),
82% (92/112) in the severe illness group. The mean RDW (CV) for mild, moderate, and severe
cases was found to be 14.21 ± 0.61, 15.32 ± 0.67, and 16.34 ± 1.64, respectively. The number of
survivors was 704 (88%). The number of people who died was 96 (12%). Elevated RDW was seen
in 74% (71/96) who died and 45% (321/704) of people who survived. To determine the efficacy of
RDW (CV) in identifying the severity of disease, a ROC curve was used in which a cutoff value of
13.65 is obtained with a sensitivity of 97.3% and specificity of 85%.
CONCLUSION: Higher RDW (CV) was found to have a significant association with clinical severity and
mortality prediction. Hence, it can be considered as one of the important hematological parameters
in the workup to efficiently stratify the patients at the earliest in COVID‑19.

Abstract:
Excessive menstruation after attaining menarche during adolescent age group is known as puberty
menorrhagia (PM). The most common presentation includes anemia due to excessive blood loss.
We are reporting a rare case of PM secondary to a congenital bleeding disorder.

Abstract:
Aplastic anemia (AA) is a rare hematological disorder which is life‑threatening in pregnancy. It is mainly
caused by the destruction of pluripotent stem cells of bone marrow. There is high risk in pregnancy
due to risk of hemorrhage and infection due to pancytopenia. Fetus is also at high risk of intrauterine
growth restriction, risk of intrauterine death, and preterm labor. Hence, managing aplastic anemia
in pregnancy is a great challenge for obstetricians. It requires a multidisciplinary approach involving
hematologist, obstetrician, and critical care specialist for the management of AA in pregnancy. We
report a case of AA with pregnancy diagnosed during first trimester.

BACKGROUND: Childhood acute lymphoblastic leukemia (ALL) is the most prevalent malignant
disease (25%–30%) and the most common type of leukemia (75%–80%) among children. It is not a
single disease with significant phenotypic and genotypic variability that has diagnostic and prognostic
implications. This study aims to provide the immunophenotypic profile of childhood ALL in Iraqi
patients and to explore the frequency of aberrant myeloid antigen expression and their association
with hematological parameters.
PATIENTS, MATERIALS AND METHODS: The records of 67 pediatric patients diagnosed as ALL
were reviewed for their flow cytometric immunophenotyping results at presentation.
RESULTS: B‑ALL constituted 76.1% of the cases and 23.9% were T‑ALL. There was a highly
significant statistical relation between higher age interval and T‑ALL phenotypes (P = 0.001).
Higher hemoglobin (Hb) level and white blood cell count were significantly related with T‑ALL
subtype (P = 0.039 and < 0.001, respectively). CD34, HLA‑DR, CD10, and CD79a were significantly
correlated with B‑ALL compared to T‑ALL (P = 0.007, <0.001, <0.001, and <0.001, respectively).
With no significant differences, aberrant myeloid antigen expression was found in 51% of B‑ALL and
in 25% of T‑ALL cases; however, CD34 expression was substantially related with aberrant myeloid
antigen expression (P = 0.001).
CONCLUSION: Aberrant myeloid antigens were expressed in 44.9% of ALL patients with insignificant
differences between B‑ and T‑ALL phenotypes. CD34 was significantly associated with B‑lineage
ALL and with aberrant myeloid antigen expression. T‑ALL children are older and have significantly
higher Hb concentration and white blood cell count. No correlation was found between aberrant
myeloid expression and hematological parameters in B‑ALL.

BACKGROUND: Iron overload certainly will develop in β‑thalassemia major. Iron homeostasis was mostly regulated by hepcidin that synthesized in the liver and encoded by the hepcidin antimicrobial peptide (HAMP) gene. HAMP and HFE genes, respectively, encode iron‑regulating proteins (Hepcidin and HFE). The iron overload’s possibility will increase if there is an interaction between β‑thalassemia and HAMP‑HFE gene mutations. AIM OF STUDY: In β‑thalassemia major patients, we need to identify mutations in iron‑regulating genes (HAMP and HFE genes), their impact on the iron overload, and their association with some clinicopathological parameters. PATIENTS AND METHODS: During a period of 5 months from (November 2020 to March 2021), a case–control study was conducted. It included 80 patients and controls aged ≥14 years and divided into two groups: thalassemic patient group included 40 patients who were diagnosed by complete blood count, blood film, and hemoglobin – electrophoresis as β‑thalassemia major and control group included 40 unrelated, apparently healthy controls that were age and gender matched with thalassemic patient group. Complete blood count, liver and renal function tests, serum ferritin, and DNA extraction were performed. RESULTS: There was a statistically significant difference between study groups by H63D mutations. The proportion of CG genotype was significantly higher among thalassemic patient group than that in controls. There was no statistically significant difference (P = 0.082) between study groups by G71D mutations. Serum ferritin and Alanine transaminase (ALT) levels were significantly higher in patients with CG and GG genotypes compared to that in patients with CC genotype of H63D. CONCLUSION: H63D is associated with iron overload in β‑thalassemia patients with unapparent effect on biochemical and hematological data except for ALT and serum ferritin. This could allow early diagnosis and proper treatment to overcome the complications of iron overload in those patients.

Abstract:
BACKGROUND: Iron replacement may change platelet counts. Parenteral iron treatment has
different effects on platelets count in some diseases. the aim of this study was to inspect the effect
of parenteral ferric carboxymaltose treatment on platelet counts and other hemogram parameters
in females who have no other diseases, but iron deficiency.
MATERIALS AND METHODS: This study was conducted in a university hospital located in Ankara,
Turkey, between January 2020 and October 2021. A total of 239 female participants who were
diagnosed with iron deficiency and who were given parenteral ferric carboxymaltose treatment were
included in the study. Participants were divided into two groups according to the existence of anemia.
Hemogram parameters, ferritin, and C‑reactive protein levels before and 3 months after parenteral
ferric carboxymaltose treatment were compared between these two groups.
RESULTS: Hemoglobin and ferritin levels were increased (P < 0.001) and platelet counts (P < 0.001)
and mean platelet volumes (MPVs) (P = 0.015) were decreased after parenteral ferric carboxymaltose
treatment. In both groups, hemoglobin levels were increased and platelet counts were decreased,
but in the group with patients having anemia, changes in hemoglobin levels and platelet counts were
more prominent after treatment (P < 0.001). When compared to initiation of treatment, there was a
significant negative correlation after treatment regarding changes in hemoglobin levels and platelet
counts (r = ‒0.369, P < 0.001).
CONCLUSION: Parenteral ferric carboxymaltose treatment resulted in a decrease in platelet counts
and MPV values compared to initiation of treatment. Parenteral ferric carboxymaltose treatment
resulted in decreases in platelet counts and independent from correction of anemia.

Abstract:
BACKGROUND: Thalassemia syndromes and structural hemoglobin variants generate blood crisis
of variable clinical symptoms, ranging from mild‑to‑moderate hematological disorder to severe,
lifelong, transfusion‑dependent anemia. The aim of current study was to uncover the prevalence of
thalassemia and other hemoglobinopathies in the Erbil governorate, Kurdistan region of Iraq.
MATERIALS AND METHODS: The available data of thalassemia major, thalassemia intermedia,
sickle cell disease, sickle cell trait, and HbH and HbE until the end of 2020 were collected
retrospectively from Erbil Thalassemia Center in Erbil governorate, Kurdistan region of Iraq and
analyzed by using Microsoft Excel (Version 2016).
RESULTS: An increase in the prevalence of thalassemia syndromes from 30.8/100,000 in
2015 to 37.3/100,000 individuals in the population in 2020 was revealed. The prevalence of all
hemoglobinopathies combined increased from 31.9/100,000 to 42.7/100,000 individuals of the
population. Thalassemia major was the predominant condition among the hemoglobinopathies with
758 (78.71%) cases out of 963 cases at the end of 2020.
CONCLUSION: This rise might be attributed to a large number of consanguineous marriages, the
lack of effective prevention programs, and poor legislation. There is an emergent requirement for a
preventive program, entailing identification of carriers, genetic counseling, guidelines to differentiate
between other microcytic anemias with thalassemia traits, antenatal diagnosis, public education,
and sustained legislation.

BACKGROUND: Acute lymphoblastic leukemia (ALL) is a heterogeneous disorder characterized
by the proliferation of immature lymphoid cells that accumulate in the bone marrow, peripheral
blood, and extramedullary sites, causing the clinical manifestations of the disease. Lymphoid
enhancer‑binding factor‑1 (LEF1) is a target gene and central mediator for the Wingless‑type
signaling pathway, and it has an important role in normal hematopoiesis. High LEF1 expression
was reported as a prognostic marker in many types of hematological and nonhematological
malignancies.
AIM OF THE STUDY: To evaluate the serum level of LEF1 in pediatric patients with ALL and its
correlation with other hematological and clinical prognostic factors (white blood cells [WBC] count,
age, gender, central nervous system involvement, and response to treatment).
PATIENTS, MATERIALS, AND METHODS: This cross‑sectional study was conducted on 60 children;
20 patients with newly diagnosed ALL before starting induction therapy, 20 patients with ALL during
remission (postinduction), and 20 healthy controls. Measurement of serum LEF1 level was done by
enzyme‑linked immunosorbent assay.
RESULTS: Serum level of LEF1 was higher in newly diagnosed patients than in either patients at
remission or controls with highly significant differences. There is a significant positive correlation
with total WBC count and no significant correlation between LEF1 level and other hematological
and clinical parameters or with immunophenotypic subtypes. There was no significant correlation
between LEF1 serum level and response to remission induction.
CONCLUSION: A high serum concentration of LEF1 is found in newly diagnosed patients with ALL
and showed a significant positive correlation with total WBC count.

BACKGROUND: Anemia of β thalassemia results from a combination of ineffective erythropoiesis
and hemolysis. This stimulates erythropoietin (EPO) production, which causes expansion of the bone
marrow and may lead to serious deformities of the skull and long bones. Ineffective erythropoiesis
also induces the release of growth differentiation factor 15 (GDF‑15) and transforming growth
factor‑beta (TGF‑β) which have been identified as regulators of hepcidin expression.
OBJECTIVE: The objective is to evaluate the level of TGF‑β, GDF‑15, and EPO in patients with
thalassemia syndrome.
PATIENTS, MATERIALS AND METHODS: Patient samples were collected from Thalassemia
Center of Ibn Al‑Baladi Hospital. This study included 35 patients with thalassemia, 18 patients with
beta‑thalassemia major and 17 patients with beta‑thalassemia intermedia. The age of studied group
was 3–17 years. Twenty control healthy subjects were included for comparison who were age‑ and
sex‑matched with the patients group. Gel tube was used for collection of serum for enzyme‑linked
immunosorbent assay test for GDF‑15, TGF‑β, and EPO).
RESULTS: There was a highly significant difference in GDF‑15 and EPO levels among studied
groups (P < 0.001). In addition, there was no significant difference in TGF‑β level among studied
groups (P > 0.05). TGF‑β, GDF‑15, and EPO were not significantly correlated to splenomegaly,
hepatosplenomegaly, and frequency of blood transfusion duration in patients with beta‑thalassemia
major (P > 0.05), while TGF‑β and EPO were significantly correlated to splenomegaly,
hepatosplenomegaly in patients with beta‑thalassemia intermedia but GDF‑15 was not significantly
correlated. In patients with beta‑thalassemia major, EPO was negatively correlated to hemoglobin,
packed cell volume, mean corpuscular volume, and red blood cells (RBC) count whereas GDF‑15
significantly correlated to lymphocyte and neutrophil counts. TGF‑β was significantly correlated to
platelet count. In patients with beta‑thalassemia intermedia, EPO and GDF‑15 were not correlated
to any hematological parameters whereas TGF‑β was significantly correlated to RBC counts.

Abstract:
BACKGROUND: Febrile neutropenia (FN) is a serious problem, especially in hematologic
malignancies, and can cause high mortality rates and it occurs in 10%–20% of patients with
lymphoma. The aim of this research is to assess the risk factors for FN, and the impact of FN on
overall survival (OS) in patients with diffuse large B‑cell lymphoma (DLBCL).
MATERIALS AND METHODS: The study included 263 patients who were diagnosed with DLBCL
and treated with mostly R‑CHOP‑based chemotherapy. Data including gender, age, Ann Arbor stage,
International Prognostic Index (IPI) score, immunohistologic subtype, treatment regimens, response
to treatment, and any FN episode were recorded. The factors predicting FN were analyzed.
RESULTS: Significant predictors of FN were the number of chemotherapy lines received and IPI
score. The median OS was significantly different between DLBCL patients who had at least one FN
episode during the first‑line chemotherapy and those who did not (P < 0,001). Significant predictors
of OS in the multivariate analysis were the number of chemotherapy lines received, stage, Eastern
Cooperative Oncology Group, and disease status.
CONCLUSION: Our study reveals that OS is significantly shorter in patients who had an FN episode
than those who did not. Therefore, it is crucial to demonstrate all factors related to FN to prevent FN
episodes. In our study, the number of chemotherapy lines received and IPI score was found to be
significant predictors of FN. Close follow‑up should be done in these patients as the risk of FN is higher.

BACKGROUND: A case − control study was carried out to evaluate the health‑related quality of life
of adult hemophilic patients.
MATERIALS AND METHODS: All registered hemophilia cases (40 cases, 36 hemophilia A and 4
hemophilia B) at Jin Blood Center in Duhok/Iraq as well as 40 normal age‑matched healthy male
individuals were assessed using the medical outcome study “MOS‑SF (version 1.0)” so called RAND
36‑item health survey 1.0, that assess eight health status scales namely: physical functioning,
role‑limitation due to physical health, role‑limitation due to emotional problem, vitality (energy/fatigue),
emotion well‑being, bodily pain, social functioning, and general health.
RESULTS: The study included eight patients with mild hemophilia, 18 patients with moderate
hemophilia, and 14 patients with severe hemophilia, with ages range from 17 to 57 years with the
mean age of 27.85 years (±1.65). Patients with severe hemophilia were diagnosed significantly at
earlier age compared with those with mild hemophilia. The study confirmed significantly reduced
quality of life (QoL) in all 8 assessed areas particularly among severely affected patients with a
P value consistently <0.001. The most affected domain was the role limitation due to physical health
at 22.56% and emotional well‑being at 32.71. All assessed areas were significantly preserved if
early prophylaxis initiated. Other factors that were linked significantly with diminished QoL include
the development of hemophilic arthropathy. The factors that did not show significant impact included
positive viral hepatitis markers, presence of life‑threatening bleedings, socioeconomic state, and
positive family history.
CONCLUSION: Hemophilic patient displayed significant impairment of QoL, particularly after the
development of arthropathy and restriction of physical activity and can be preserved with early
prophylactic therapy.

Abstract:
BACKGROUND: Sickle cell disease (SCD) is the second‑most common hemoglobin disorder in
Duhok governorate. Health‑related quality of life (HRQoL) instrument provides physicians with the
patient’s perspectives of their disease and thus more patient‑oriented care.
MATERIALS AND METHODS: In this case–control study, a total of 70 adults (≥18 years old)
registered as SCD at the center for blood diseases in Duhok as well as 70 age‑ and sex‑matched
healthy controls were enrolled. Enrolled patients had their records and treatment reviewed, were
clinically assessed, and appropriately investigated. All patients and controls had their HRQoL
scored using the SF36 questionnaire, which consists of eight domains, namely physical function,
role limitation physical, role limitation emotional, vitality, emotional well‑being, social function, bodily
pain, and general health perception.
RESULTS: The mean standard deviation age of the SCD patients enrolled was 26.2 (8.9) years and
included 32 males and 38 females. The patients had significantly lower HRQoL scores in all eight
domains when compared to their matched controls. The most affected domain was general health.
Within the patients’ group, it was noted that HRQoL scores were negatively correlated with age in
several domains, most significantly with general health (P = 0.011). On the other hand, there was no
significant difference in HRQoL in relevance to gender, marital status, education, or employment. The
most significant negative correlations of HRQoL scores were documented with the annual number
of pain episodes and hospital admissions observed with all eight domains.
CONCLUSIONS: The current study documented that in adults with SCD, HRQoL in all domains
was significantly worse than in healthy controls and that it gets worse with age. The most significant
contributors to the worse HRQoL are pain episodes and hospital admissions. The study underscores
the importance of HRQoL assessments to enable attending physicians provide more patient‑centered
management.

Abstract:
BACKGROUND: Blood transfusion carries the risk of transfusion‑transmissible infections (TTIs) if
not properly screened. As per protocol blood donors who are found reactive for TTIs are requested
to come for counseling and directed for further management. Many of them are either not interested
or do not follow‑up their visit to blood center. This study is undertaken to determine the rate of
seroprevalence of TTIs and the attitude of reactive blood donors in response to post donation
notification and counseling.
MATERIALS AND METHODOLOGY: This observational study considers the blood donations from
January 2019 to April 2021. Blood donors with reactive test results identified by different TTIs markers
were notified, and their response rates were evaluated.
RESULTS: During this study, 8904 donations were recorded out of which 171 donors were found to
be reactive (1.92%), only 142 donors were contacted (89.30%), and only 74 reactive donors could
be counseled (52.11%).
CONCLUSION: This study shows low prevalence of TTI reactivity among blood donors and
recommends strengthening of donor notification and counseling practices in blood centers and raises
the question of need for central notification system for the traceability of reactive blood donors to
prevent the spread of TTIs in the community.

Abstract:
BACKGROUND: Acute myeloid leukemia (AML) is a heterogeneous malignant disease of
hematopoietic tissue. It is characterized by accumulation of abnormal blast cells mainly in bone
marrow. Hepcidin is a small bioactive peptide hormone produced in many tissues mainly by the
liver, macrophage, and adipocyte and it has been proposed as a marker of inflammation. The aims
of study were to assess the changes in serum levels of hepcidin, interleukin‑6, and ferritin in addition
to iron‑binding capacity levels in patients with AML before and after chemotherapy treatment and to
compare their levels to healthy controls.
MATERIALS AND METHODS: This study includes 43 AML patients (24 males and 19 females).
They were divided into two groups: Group 1: Patients with AML before starting chemotherapy and
Group 2: after chemotherapy. The protocol used was (3 + 7) where doxorubicin was given from day
1 to day 3 and Cytarabine (Ara‑C) was given from day 1 to day 7 then evaluation is done on 28th day
to evaluate response of patients. The control group (Group 3) included 43 healthy controls (24 males
and 19 females) who were matched with patients group in gender and age.
RESULTS: Serum samples were investigated before and after treatment and compared with its
corresponding data of healthy control group and then statistically analyzed. Results revealed that:
the prevalence of AML was higher in males than in females. Hepcidin levels were significantly
higher in serum of (AML) patients (Group 2) compared to newly diagnosed (Group 1) and to healthy
controls (P < 0.0001). Serum (interleukin‑6) levels were higher but not statistically significant
in (Group 1) when compared to (Group 2) while it was statistically significantly when compared to
healthy controls (P < 0.214 and P < 0.0001, respectively). Regarding serum levels of ferritin and total
iron capacity (TIBC) predicted highly significant increase for all patients when compared to controls.
CONCLUSION: Hepcidin and interleukin‑6 may be used as diagnostic criteria for treatment response
of AML and also can utilized as biomarkers for the progression of the AML.

Abstract:
BACKGROUND : Some of the platelet count disorders have no single clinical or laboratory
diagnostic finding and bone marrow examination may be required which is invasive, time
consuming. Platelet indices are readily available parameters by recent hematology autoanalyzers
and could provide some important information and can differentiate between several mechanisms
of platelet disorders.
AIM OF STUDY: To evaluate and interpret different platelet indices (plateletcrit, mean platelet
volume [MPV], platelet distribution width [PDW], platelet‑large cell ratio [P‑LCR]) in patients with
quantitative platelet disorders.
PATIENTS AND METHODS: A prospective cross‑sectional study was carried out from November 2019
to September 2020 in different Iraqi hematology centers and conducted on 160 adult patients from 3
hematology centers, from November 2019 to September 2020, 80 patients have thrombocytopenia,
and 80 patients with thrombocytosis. Platelet count and indices (MPV, P‑LCR, PDW) were determined
using automated analyzers. For each hematological parameter, two measurements were taken at
different time interval and the mean value of these two records was relied on.
RESULTS: A significant increase in all platelet indices (MPV, PDW, P‑LCR) with cutoff values of 7.9
femtoliters (fl), 15.3%, and 12.6%, respectively, P = 0.000 was observed in primary thrombocytosis,
with 90% sensitivity for MPV and 50% specificity for PDW. In immune thrombocytopenia (ITP),
all platelet indices (MPV, PDW, and P‑LCR) were significantly higher than in hypoproductive
thrombocytopenia with cutoff values of 7.9fl, 15.3%, and 12.9%, respectively. MPV has a sensitivity
of 97% and specificity of 50%, P‑LCR had a sensitivity of 100%, and PDW had a sensitivity and
specificity of 77% and 70%, respectively.
CONCLUSIONS: These abnormalities in platelet indices are of value for differentiation of platelet
quantitative disorders, higher value in ITP in comparison with other causes of thrombocytopenia,
and for primary thrombocytosis, the value is higher than reactive thrombocytosis.