Iraqi Journal of Hematology

Abstract:
BACKGROUND: Corona virus disease 2019 (COVID-19) is a coronavirus that can produce a variety
of symptoms, ranging from asymptomatic carrier status to severe respiratory failure, multiple organ
dysfunction, and death, it might be associated with hypercoagulability as increase in coagulation
factor 8 (FVIII).
OBJECTIVES: This study was carried out to investigate markers of hypercoaguablility
(factor VIII activity, D‑Dimer) in hospitalized adult patients with COVID‑19, evaluation of certain
markers of inflammation (S. ferritin, lactate dehydrogenase [LDH], C‑reactive protein [CRP], and
erythrocyte sedimentation rate [ESR]) and correlate those markers with each other.
PATIENTS AND METHODS: This cross‑sectional study included 70 adult hospitalized patients with
COVID‑19. Blood samples were obtained for FVIII, D. dimer, and ESR. Statistical analysis was performed
using Statistical Package for Social Sciences (SPSS) version 23 and Microsoft Office Excel 2010.
RESULTS: The mean age of enrolled 70 patients was 60.22 ± 14.43 years. 44 (62.9%) of patients
had neutrophilia and lymphopenia was seen in 41 (58.6%). High ratio of N/L was seen in 66 (94.3%).
Low count of eosinophil was seen in 44 (62.9%), high LDH level was seen at 57 (81.4%). Regarding
serum ferritin, high level was seen 64 (91.4%) and high level of CRP was seen in 56 (80%). High
level of ESR was seen in 64 (91.4%) and high level of D. dimer was seen in 55 (78.6%), while the
high level of FVIII was seen in 30 (42.9%) and low FVIII level was seen in 4 (5.7%).
CONCLUSIONS: The majority of patients had neutrophilia, lymphopenia, high N/L ratio, and
eosinopenia. Markers of inflammation (S. ferritin, LDH, CRP, and ESR), which were elevated. FVIII
level and D. dimer were elevated in the majority of patients with COVID‑19. Few of the patients were
had a low level of FVIII, which might be related to abnormal function of the liver or might be attributed
to autoantibodies directed against FVIII.

BACKGROUND: Non‑Hodgkin lymphoma (NHL) patterns vary worldwide in relation to demographic
and environmental factors.
AIM: The objective of our study was to identify subtypes of NHL in the Middle Euphrates Region of
Iraq according to the World Health Organization (WHO) modified classification.
MATERIALS AND METHODS: A retrospective descriptive study was carried out at Al‑Hussein Cancer
Center in Karbala, Iraq, on 385 patients diagnosed with NHL between January 2012 and August
2020. Patient ages ranged between 1 and 96 years. They included 204 males and 181 females. All
patients were diagnosed by tissue biopsy, confirmed by immunohistochemistry markers, and classified
according to WHO classification. Any patient with inconclusive results was excluded from the study.
RESULTS: Among total NHL patients, males were (53%) and females were (47%) with a male: female
ratio of (1.12:1). B‑cell lymphoma was diagnosed in (92.47%) and T cell lymphoma in (7.53%).
Diffuse large B‑cell Lymphoma (DLBCL) was the most frequent B‑cell subtype (54.02%) followed
by Burkitt’s lymphoma (BL) (14.02%), while peripheral T‑cell lymphoma was the most common
T‑cell subtype (2.08%). About (61.82%) of patients were nodal, and (38.18%) were extranodal. The
intestine was the most frequent extranodal site (34.69%).
CONCLUSION: Among our patients, there were high frequencies of DLBCL, extra nodal primaries and
intestinal BL. Follicular lymphoma and small lymphocytic lymphoma were uncommon in our region.
These results were similar to the Middle Eastern NHL patterns but differed from the western patterns.

Abstract:
INTRODUCTION: Basophilia can help stratify cases of chronic myeloid leukemia (CML) into different
phases and monitor response to therapy and has a significant prognostic value. It helps differentiate
patients of CML from those with leukemoid reaction. Basophil counts (BCs) given by automated
hematology analyzers are often not reliable. Analysis of peripheral blood picture therefore holds its
importance in these cases. In this study, we aim to compare the BC in patients with suspected CML
using two automated analyzers with manual microscopy.
MATERIALS AND METHODS: Two hundred and sixty‑nine ethylenediaminetetraacetic acid
samples identified as suspected CML run on Beckman Coulter UniCel DxH 800 and Sysmex
XN‑1000 were analyzed for BC microscopically on Giemsa‑stained peripheral smear slides by
two pathologists. The mean of basophil counts obtained microscopically was considered to be
standard. They were compared with BC given by automated counters using correlation analysis
and Bland Altman plots.
RESULTS: The age of the patients ranged from 4 to 89 years, with a male‑to‑female ratio of 1.2:1
(148 males; 121 females). BC obtained among both analyzers did not correlate (r2 = 0.14). Results
of microscopically counted basophils correlated well among two pathologists (r2 = 0.92). Bland–
Altman plots showed a mean bias of 2.2% and 2.4% by XN‑1000 and DxH 800, respectively, when
compared with manual counts. In the frequency distribution analysis, XN‑1000 missed all 10 cases
with BC >20% whereas DxH 800 missed 3/10 cases with BC >20%. In addition, in the 10%–20%
range of BC, XN‑1000 identified 6/22 cases whereas DxH 800 identified 12/22 cases. In the 5%–10%
range of BC, XN‑1000 identified 59/78 cases whereas DxH 800 identified only 43/78 cases.
CONCLUSION: With lower BC, Sysmex XN‑1000 and, at higher BC, Beckman Coulter DxH 800
showed better performance. However, BC from none of the analyzers can be used alone without
consideration of the microscopic results. All smears should be manually counted for basophils in
cases of suspected CML because of its importance in clinical management.

Abstract:
CONTEXT: Hemoglobin H (HbH) disease is induced by mutations in three out of the four α‑ globin
genes. Most commonly, mutations are either deletional or nondeletional. While some deletions (3.7
and 4.2) induce α+ thalassemia, others induce (20.5, MED, THA1, FIL) α0 thalassemia. HbH disease
is a combination of both.
AIMS: This study aimed to describe alpha‑thalassemia (HbH disease) mutations in Suliamaniyah
Province, Iraq.
MATERIALS AND METHODS: Fifty‑one patients with hypochromic microcytic anemia were evaluated
for HbH disease. For each patient, a 2‑ml venous blood sample was taken for isolating DNA. The
samples were inspected for HbH disease mutations by gel electrophoresis, applying the α‑Globin
Strip Assay from the Vienna Lab TM commercial kit.
STATISTICAL ANALYSIS: Microsoft Excel software was used to analyze data.
RESULTS: Clinical data from complete blood count, hemoglobin (Hb)‑electrophoresis, and HbH
test were measured. HbH patients had significantly low levels of mean corpuscular volume, mean
corpuscular Hb, and Hb (HGB) compared to normal values, and all showed a positive result in
the HbH test with a low level of HbA2. Both the Med double gene deletion (3.7/MED) and the 3.7
single‑gene deletion were detected in 68.62% of patients. Single‑gene deletion 4.2, double gene
deletion 20.5 (4.2/20.5), double gene deletion Med, and point mutation α2 poly A2 (MED/α2 poly
A2) were all found in 1.96% of patients.
CONCLUSION: There is no difference between the phenotypes of patients with different genotypes.

Human parvovirus B19 among
hemophilia A patients in Basrah,
Southern Iraq
Murtadha A Al-khegane, Wijdan Nazar Ibrahim, Meaad Kadhum Hassan1
Abstract:
BACKGROUND: Hemophilia A patients, especially if there is shortage in recombinant Factor VIII
concentrate, may require occasional blood and/blood products transfusion, rendering them more
susceptible to acquire infections including Parvo B19 virus (B19V).
OBJECTIVES: To assess the presence of B19V viral DNA among hemophilia A patients and look
for its possible association with disease‑related variables.
SUBJECTS AND METHODS: This case–control study was carried out from October 2019 to August
2020. A total of 95 male patients with Hemophilia A and 95 healthy subjects matched for age and
gender were enrolled in the study. The identification of B19V DNA was achieved using the real‑time
polymerase chain reaction (PCR). Hepatitis C virus (HCV) antibodies and hepatitis B surface
antigen (HBsAg.) were tested by ELISA method.
RESULTS: The frequency of B19V among hemophilia A patients was 13.7% compared to 6.3%
among healthy subjects. None of the control group has been tested positive for HCV antibodies or
HBsAg. While among patients, the frequencies of hepatitis C and B were 8.4% and 2.1%, respectively.
Patients with hemophilia A and B19V have significantly higher rate of arthropathy at the time of
blood sampling and blood and/blood products transfusion, especially fresh‑frozen plasma (FFP) and
cryoprecipitate compared to those who did not receive such blood products (92.3% vs. 50%), P < 0.05.
CONCLUSIONS: Parvovirus B19 was detected in a significant proportion of hemophilia patients
especially those with a history of FFP and cryoprecipitate transfusion. The use of PCR technique is
essential to detect viruses in donor’s blood to avoid infection among this high‑risk group.

Abstract:
BACKGROUND: Aberrant antigen expression is an unexpected antigen that is detected on lineage
in question without alteration of lineage definition. Immunophenotypic aberrancies are thought to
predict treatment outcome in acute myeloid leukemia (AML). Some studies reported an adverse
prognostic association, while others failed to show any association.
AIM: To determine percentage of lymphoid antigens expression in adult AML patients and correlate
them with hematological parameters and response to induction chemotherapy protocol.
SUBJECTS AND METHODS: Peripheral blood and bone marrow fresh samples from 81 cases
of de novo AML were included in this study from November 2018 to October 2019. Hematological
parameters were obtained from patients’ medical records. Aberrant antigens expression was detected
using flow cytometry at the diagnosis. Patients were evaluated after one cycle of chemotherapy
regarding remission status.
RESULTS: Out of 81 patients, 60 patients had completed data for evaluation. CD7, CD19 expression,
and co‑expression of CD7 and CD2 were found in 60%, 10.7%, and 10.7% of patients, respectively.
Statistically significant associations were found between initial hemoglobin level and aberrant
expression as patients with aberrant expression have higher hemoglobin level than patients without
aberrant expression. Complete remission was achieved in 29 out of 60 patients (48.3%) with standard
3 and 7 protocol, whereas 31 patients did not achieve complete remission. There is no statistically
significant association between aberrant expression and treatment response to the first cycle of
chemotherapy protocol (P > 0.05).
CONCLUSIONS: CD7 is the most frequent aberrant antigen expressed in this Iraqi AML patient
group. Hemoglobin level was higher in patients with aberrant expression. No significant association
between aberrant expression and response to the first cycle of induction.

Abstract:
BACKGROUND: The clinical course of patients with chronic lymphocytic leukemia (CLL) is
heterogeneous. Certain patients go through a brisk illness progression, and others stay alive for
quite a long time without requiring treatment.
OBJECTIVE: This study was conducted to evaluate the impact of clinical staging, age, gender, and
treatment initiation on the survival of CLL patients in Kurdistan‑Iraq.
MATERIALS AND METHODS: A total of 239 CLL patients from Oncology Centers from Kurdistan‑Iraq
were enrolled in a retrospective study from January 1, 2010, to December 31, 2020. A standardized
questionnaire was used to obtain demographics data, presenting features, blood investigations, and
imaging results. The diagnosis and treatment assessment was based on the International Workshop
of CLL, and clinical staging was performed using both Rai and Binet classifications. There were two
groups of patients (watch and wait) and (treated) groups.
RESULTS: The median age at the diagnosis was 64 years old with a male: female ratio of 2.3:1.
Eighty‑three patients (34.7%) were diagnosed incidentally and about one‑third of the patients
presented with advanced stage, and also, 62.3% of the patients received therapy throughout the
study period. The 3‑year overall survival was (81.1%) (95% confidence interval 74.3%–87.9%). Of
particular interest to report that advanced age, Binet Stage C, and hemoglobin <10 g/dl have adversly
impacted the outcome.
CONCLUSION: Despite the study limitations, the resulted CLL outcome approximates the Western
countries reported figures.

Abstract:
BACKGROUND: Tracking transfusion reactions is essential to improve patient safety. Under‑reporting
of transfusion reactions was suspected in our institution. To evaluate this phenomenon, we followed an
active surveillance protocol for transfusion reactions for 3 months in 2016 and compared transfusion
reaction rates during that period with 2015 and 2017.
METHODS: The study was carried out in a tertiary care hospital over 3 months in 2016. Investigators
visited hospital units and collected data on all patients who received a transfusion in the preceding 24 h.
Further details were obtained about all cases that are suspected to have had a transfusion reaction.
Transfusion reactions were defined according to the definitions provided by National Healthcare
Safety Network Biovigilance Component Hemovigilance Module Surveillance Protocol 2016. Rates
that were obtained through active surveillance were compared through appropriate statistical methods
with transfusion reaction rates obtained through passive reporting from 2015 and 2017.
RESULTS: During the study period, a total of 47 transfusion reactions were captured through
active surveillance and passive reporting (transfusion reaction rate 0.79%). There was a statistically
significant difference between these rates in comparison with rates detected in similar months from
2015 (0.26%) and 2017 (0.17%).
CONCLUSIONS: Active surveillance for transfusion reactions is an effective method for improving
rates of the detection of suspected transfusion reactions. The phenomenon of under‑reporting of
transfusion reactions requires thorough evaluation by transfusion medicine professionals to introduce
targeted solutions and improve reporting rates.

Abstract:
BACKGROUND: Chronic lymphocytic leukemia (CLL) is characterized by a lower incidence rate
in Iraq and Kurdistan as compared to Western countries. However, a good prognosis of CLL is
dependable on diagnosis, risk stratification, and a better choice of an appropriate treatment regimen.
AIM OF THE STUDY: To evaluate the effectiveness of fludarabine, cyclophosphamide, and
rituximab (FCR) regimen in comparison to other chemotherapy regimens in the management of
patients with CLL in Kurdistan region/Iraq.
PATIENTS AND METHODS: A retrospective review study carried out in three cancer centers in
the Kurdistan region of Iraq for the duration of 10 years through the period from January 1, 2010
to December 31, 2019, on 152 CLL patients. CLL was diagnosed according to the International
Workshop on CLL. The treatment of CLL patients was either by FCR chemo‑immunotherapy regimen
or other chemotherapies.
RESULTS: The FCR chemo‑immunotherapy was the treatment of 38.8% of CLL patients, while 61.2%
of CLL patients were treated by other chemotherapies. There was a significant association between
younger age patients and the use FCR chemo‑immunotherapy (P = 0.001). There was a significant
association between a complete response and treatment by FCR chemo‑immunotherapy (P = 0.02).
The mean overall survival duration and progression‑free survival of CLL patients treated by FCR
chemo‑immunotherapy were significantly longer than the mean survival time of CLL patients treated
by other chemotherapies (P = 0.01).
CONCLUSIONS: Complete response and survival of CLL patients treated by FCR chemo‑immunotherapy
were better than the complete response and survival of CLL patients treated by other chemotherapies.

Abstract:
BACKGROUND: Imatinib Mesylate (IM) is an oral tyrosine kinase inhibitor, which demonstrates
great effect in the treatment of both chronic myeloid leukemia (CML) and gastrointestinal stromal
tumors. The effects of this chemotherapeutic drug on women with child bearing age, fertility, and
reproductive system have been reported in some studies as case series; therefore, this study was
designed to demonstrate the outcome of imatinib on females with child‑bearing age.
PATIENTS AND METHODS: This is a prospective cross‑sectional study conducted in the National
Center of Hematology/Mustansiriyah University in Baghdad. The study started on February 2018
and was ended in July 2020. It included 55 female patients. A questionnaire was designed to elicit
the effects of imatinib mesylate on fertility and outcome of pregnancies.
RESULTS: Out of 55 women diagnosed with CML in chronic phase, 13 patients were able to conceive
during the study. All of them were treated with imatinib mesylate 400 mg per day before pregnancy.
All of them were at least in complete cytogenetic response. Four (30.7%) pregnant patients continued
treatment throughout pregnancy with uneventful pregnancy and delivery, without any congenital
anomalies. other 4 (30.7%) pregnant patients received IM during 1st and 2nd trimester only and then
discontinued treatment with IM. Five (38.4%) pregnant patients who received IM during 1st trimester
ended with abortion (either elective or missed abortion).
CONCLUSION: Treatment of CML with IM during the pregnancy has different perspectives and the
data are still limited. Hence, each case decision should be individualized balancing the risk to the
fetus of continuing IM versus the risk to the mother of interrupting treatment.

Abstract:
BACKGROUND: Neonatal sepsis is a life‑threatening condition which needs urgent diagnosis and
proper management. Blood culture and sepsis screening are currently used methods, but their utility is
limited due to delayed reporting and increased cost. However, in newborn infants, a close relationship
between sepsis and thrombocytopenia and other changes in platelet indices such as increased mean
platelet volume (MPV) and platelet distribution width (PDW) has been suggested by few studies.
OBJECTIVE: This study aimed to assess the diagnostic value of platelet indices in the early detection
of neonatal sepsis.
MATERIALS AND METHODS: A retrospective study with diagnostic testing was carried out by
collecting data from medical records of neonates with neonatal sepsis who were admitted to the
Neonatology Department in DR. B. C Roy PGIPS, Kolkata, over the period from January 2019 to
December 2019. One hundred neonates were included in the study, 50 were proven to have sepsis
by culture, and others are used as controls (apparently healthy babies). Sensitivity, specificity, positive
predictive value, and negative predictive value of platelet count, MPV, and PDW in neonatal sepsis
were determined using a 2 × 2 table.
RESULTS: The platelet count was significantly decreased, whereas PDW and MPV were increased
in septic babies (P < 0.0001).
CONCLUSION: Platelet indices can be used to diagnose neonatal sepsis as easily available and
cheaper markers.

Abstract:
INTRODUCTION: Blood transfusion is essential for saving lives in millions of patients. However, blood
transfusion also carries the risk of transfusion‑transmissible infections (TTIs) if not properly screened.
AIMS AND OBJECTIVES: To study the seroprevalence of TTI among blood donors in a blood bank
with special emphasis on hepatitis B and hepatitis C.
MATERIALS AND METHODS: It is a retrospective descriptive study for 5 years from January 2016
to December 2020. Data of all blood donors both voluntary and involuntary were analyzed to find
out seroprevalence of TTIs.
RESULTS: Total 43775 donors were screened, and their data were analyzed. Out of these, total
182 (0.42%) donors were found to be seropositive for TTIs. Most of the donors were positive for
hepatitis B (n = 122, 0.28%) and hepatitis C (n = 51; 0.12%); however, no donor was found to be
positive for malaria.
CONCLUSION: In this study, we found a low prevalence rate of TTIs among blood donors. It may
be due to effective screening and selection of donors as well as awareness among general public.
Strict screening and regular testing are essential to keep blood transfusion safe and free from TTIs.

Abstract:
While simple serological tests such as forward and reverse grouping can help identify rare phenotypes,
their Confirmation is to be done with a battery of other serological tests including adsorption elution
and nonserological tests such as saliva testing for secretor status. Two cases of H‑deficient secretor
state (para‑Bombay) and one case of a weak B phenotype are presented here highlighting the
importance of nonserological tests. Case 1: A 50‑year‑old male who is a repeat blood donor, with no
significant history, had “O positive” by forward grouping, “B” by reverse, and no reaction with anti‑AB
antisera or anti‑H lectin. Adsorption elution showed the presence of weak B antigen and saliva testing
confirmed secretor status for B and H antigen. Case 2: A 25‑year‑old primigravida, with no significant
history, had “O positive” by forward grouping, “B” by reverse, and no reaction with anti‑AB antisera or
anti‑H lectin. However, adsorption elution showed the absence of any antigen on RBCs. The saliva
testing confirmed secretor status for B and H antigen. Both of them were compatible (Coomb’s major
and minor) with “B” and “O” units and were grouped as para‑Bombay B. Para‑Bombay phenotypes can
present with complete or partial suppression of ABH antigens and nonserological tests are valuable
in their diagnosis. Case 3: A 27‑year‑old first‑time blood donor, with no significant history, also had
“O Positive” by forward grouping, “B” by reverse grouping, and no reaction with anti‑AB antisera.
Furthermore, 3+ reaction with anti‑H lectin was noted. Saliva testing confirmed secretor status for
B and H antigens. He was also compatible with “B” and “O” units and was grouped as “Weak B.”
Further classification was not possible as adsorption‑elution tests could not be done.

Abstract:
OBJECTIVES: There are the variable degrees of bone marrow (BM) infiltration patterns in chronic
lymphocytic leukemia (CLL). Four BM patterns: Interstitial, nodular, mixed, and diffuse patterns were
identified. The aim of this study is to assess the effects of BM infiltration patterns on the disease
outcome among CLL patients in Kurdistan Region of Iraq.
METHODS: This study is a cross‑sectional, descriptive, retrospective involved 106 patients with
CLL disease. The data are collected in the Kurdistan region of Iraq (including Erbil, Sulaymaniyah,
and Duhok) cancer centers. Through the period from January 1, 2010 to December 31, 2019. BM
histopathology study of all patients was assessed and correlated with the disease outcome.
RESULTS: Fifty‑three (50.0%) patients had interstitial BM patterns, 17 (16.0%) had nodular BM
pattern, 14 (13.2%) had mixed BM patterns, and 22 (20.8%) had diffuse BM pattern. The results
showed that patients with interstitial, nodular, and mixed BM patterns had a superior overall
survival (OS) and progression‑free survival (PFS) rate than diffuse BM pattern. Kaplan–Meier curve
illustrates that our CLL patients with interstitial BM patterns had a better mean OS rate (44.0 months)
than diffuse BM pattern with a mean of (23.2 months). As well as for PFS, the mean was (35.7 months)
for the interstitial BM patterns and (17.6 months) for diffuse BM pattern.
CONCLUSIONS: We demonstrate that the BM involvement patterns have a prognostic value in our
CLL patients and provide more reliable information regarding the clinical outcome.

Abstract:
BACKGROUND: Chronic lymphocytic leukemia is an uncommon type of leukemia in Iraq, although
many reported cases of chronic lymphocytic leukemia in the Iraqi Kurdistan region are of high risk
stage. Staging of chronic lymphocytic leukemia is essential in treatment planning and for disease
prognosis. the aims of this study were to find out the difference in patients’ survival with early and
late clinical stages, and to evaluate CLL outcome in relation to the Rai and Binet staging.
PATIENTS AND METHODS: This retrospective cross-sectional analysis studied 250 patients, 170
male and 80 female, with chronic lymphocytic leukemia who were registered in three hemato-oncology
centers in Iraqi Kurdistan for the last 10 years. The diagnosis of the disease was made according to
the guideline of the International Workshop Chronic Lymphocytic Leukemia update of the National
Cancer Institute. The patients’ clinical staging was determined by a senior hematologist based on
the clinical and laboratory findings.
RESULTS: The mean age of the patients was 63(±11.8) years, 40% were >65 years. The median
survival was 27 months. Elderly patients >65 years had significantly lower mean survival. The Rai
staging was distributed as follows: stage 0 (24.8%), stage I (12.8%), stage II (30.8%), stage III (9.6%)
and stage IV (22%). The median survival was significantly higher among patients with Rai stage 0
comparing to patients with advanced stages (P<0.001). The Binet stage was distributed as follows:
stage A (47.2%), stage B (26.4%) and stage C (26.4%). The median patients’ survival was significantly
higher among patients with Binet stage A comparing to those with Binet stage C (P<0.001).
CONCLUSIONS: The survival of patients with chronic lymphocytic leukemia strongly related to the
clinical stages of both staging systems.

Abstract:
BACKGROUND: Mixed phenotype acute leukemias (MPALs) are a heterogeneous group of rare
leukemias, with an incidence of 2%–5% of all acute leukemias and varied clinical, cytogenetic,
immunophenotypic, and molecular genetic features. They have been reported to have a poor
prognosis, early relapse, and increased incidence of extramedullary infiltration.
MATERIALS AND METHODS: Retrospective analysis of all the acute leukemias (ALs) diagnosed
in the department of pathology over the period of August 2017 to December 2019 was done. MPAL
cases were identified in accordance with the World Health Organization (WHO) 2016 guidelines and
European Group for the Immunological Classification of Leukemias Criterion. Beckman and Coulter
FC500 flow cytometer was used using AL panel with CD3, cyCD3, CD5, CD1a, CD2, CD4, CD8,
and CD7 as the markers for T‑cell lymphoid lineage, along with CD19, CD 79a, CD22, and CD20 for
B‑cell lineage and CD13, CD33, CD 14, CD64, and myeloperoxidase for myeloid lineage/monocytic
lineage. Molecular analysis was also done.
RESULTS: Of the 153 cases newly diagnosed cases of AL during this period, 6 fulfilled the European
group for immunological characterization of acute leukemia/WHO criteria for MPAL (3.9%). The age
ranged from 3 to 13 years with male‑to‑female ratio of 1:1. Four out of the six cases (66.6%) were assigned
B‑lymphoid/myeloid type and two (33.3%) were assigned B/T lymphoid. Cytogenetics was available in
four out of six cases, among which three had a normal karyotype and one had Breakpoint Cluster Region-
Abelson Murine Leukemia 1 (Philadelphia chromosome) (BCR‑ABL) translocation (t [9;22] [q34; q11]).
CONCLUSION: Distinction at the outset is of paramount importance and the role of morphology,
flow cytometry compounded with cytogenetic/molecular studies cannot be denied.