Iraqi Journal of Hematology

Abstract:
Plasma cell leukemia (PCL) is a rare and aggressive variant of plasma cell dyscrasias that can occur
either de novo (primary) or as a leukemic transformation of end‑stage multiple myeloma (MM). PCL is
known with a poor prognosis and with a different biologic background, clinical, and laboratory features.
Primary PCL presents more often with extramedullary involvement, anemia, thrombocytopenia,
hypercalcemia, elevated serum 2‑microglobulin, and lactate dehydrogenase levels, in addition to
impaired renal function in comparison with MM. Here, we report a case of a young female who was
admitted with excessive thirst, polyuria, lower backache, fever, and weight loss over 2 months.
Peripheral blood smear showed numerous atypical looking plasma cells, and immunophenotyping on
bone marrow (BM) aspirate demonstrated the presence of clonal plasma cells. She was admitted to
adult hematology ward in Hiwa Hemato‑Oncology Hospital, Sulaimani, Kurdistan, Iraq and received
four cycles of bortezomib, thalidomide, and dexamethasone chemotherapy, followed by two more
cycles of dexamethasone, cyclophosphamide, etoposide, and cisplatin, and later, she proceeded to
autologous BM transplantation. More details of the case are presented below.

Abstract:
BACKGROUND: The bone marrow of healthy individuals is conventionally considered sterile like other
body fluids, but recently the scientists found genetic material from the bacteria inside their stem cells.
The findings raise the possibility that other infectious agents may also reside in the bone marrow.
OBJECTIVES: The study was planned to look for the presence of all type of bacteria by amplifying
16S rDNA sequences using eubacterial universal primers.
MATERIALS AND METHODS: A total of 18 bone marrow samples of apparently healthy individuals
were collected from patients admitted having closed bone fractures. The DNA was isolated and was
subjected to nested polymerase chain reaction (PCR) using Universal eubacterial 16S rDNA primers.
The samples positive by universal PCR was further checked for the presence of Salmonella Typhi,
Salmonella Paratyphi A, and/or Mycobacterium tuberculosis (Mtb) if any using a second nested
PCR reaction.
RESULTS: A total of 16 (89%) samples could yield the desired amplicon through universal PCR.
The secondary PCR of 16 samples, the desired amplicons were detected 3 (18.8%) for Mtb, 4 (25%)
for S. Typhi, and 1 (6.2%) for S. Paratyphi A.
CONCLUSIONS: Even in asymptomatic cases, other infectious agents such as Mtb, Salmonella
spp., and many other microorganisms may be present as commensal.

BACKGROUND: Splenic marginal zone lymphoma (SMZL) is a low‑grade disorder that regularly
presents with peripheral blood (PB) involvement. A precise description of clinical, laboratory
features and immunophenotypic characterization of SMZL are still lacking. Here, we reviewed
34 patients presenting with SMZL to describe the clinical, hematologic features, and flow cytometry
immunophenotypic findings of this type of lymphoma at diagnosis.
OBJECTIVES: The aim of this study is to confirm that SMZL has a specific immunologic profile which
enables the hematopathologist and clinician to differentiate this low‑grade B‑cell lymphoma from other
B‑cell lymphoproliferative disorder, especially chronic lymphocytic leukemia and hairy cell leukemia,
which could sometimes stimulate SMZL morphologically and to emphasize that a correlation of
immunophenotypic findings, clinical, and hematologic features of patients plus careful morphological
examination of PB and/or bone marrow (BM) aspirate can lead confidently to the correct diagnosis.
MATERIALS AND METHODS: Flow cytometry immunophenotypic findings of 34 cases of SMZL were
reviewed. The analysis was performed by BD FACS Calibur™ and FACSCanto II flow cytometers.
B lymphocytes were identified according to their Side-Scattered (SSC)/CD19 distribution. A marker
was considered positive when expressed in more than 20% of cells above the control.
RESULTS: Median age was 60 years, range (35–84 years), both sexes were affected equally. All
patients presented with splenomegaly, 71% of patients had absolute lymphocytosis and 88% of
patients showed PB involvement. Seventy‑four percent of patients had anemia and (53%) of them
had thrombocytopenia. Cells from all cases expressed pan B‑cell antigens (CD19, CD20), 74% of
cases expressed CD79b and Human Leukocyte Antigen – antigen D Related (HLA-DR) expressed
in nearly almost all cases (97%). Half of the patients expressed CD11c and SIgD, 41% expressed
CD5 and FMC7 while CD25 and CD103 showed positivity in less than 5% of cases. Preferential
expression of Kappa light chain was demonstrated, CD10 and CD38, SIgG were negative.
CONCLUSION: SMZL has a distinct immunologic profile which if correlated with morphologic findings
of PB or BM aspirates, clinical and hematologic features can help to make the accurate diagnosis
and lessens the need of further invasive diagnostic procedure.

Abstract:
BACKGROUND: Acute myeloid leukemia (AML) is a common acute leukemia in adult. Recent studies
have shown that cytokine systems influence leukemic cell biology and clinical investigations. Among
various cytokines, interleukin‑6 and interleukin‑10 (IL‑6 and IL‑10) participate an essential function
in progression of the disease.
OBJECTIVE: The aim of this study is to quantify of IL‑6 and IL‑10 levels in AML patients who are
newly diagnosed and evaluate lipid profile to assess the relationship between lipid profile level and
body mass index (BMI) in myeloid leukemic patients.
MATERIALS AND METHODS: Samples were collected from 45 patients with AML from AL‑Yarmouk
Teaching Hospital in addition to another 45 healthy individuals were served as a control group during
a period from October 2015 to October 2016. Patients ages ranged from 40 to 60 years. IL‑6 and
IL‑10 were measured in all patients before any treatments and compared with control group.
RESULTS: There was an increase in age, white blood cell, and hemoglobin in AML patients as
compared to control, but it was not significant. There was a significant increase in neutrophils and
lymphocyte count, (P = 0.001). Furthermore, there was an increase in BMI, fasting blood sugar,
and lipid profile except high‑density lipoprotein cholesterol for AML patients as compared to control,
but it was not significant. There was a significant increase in serum IL‑6 and IL‑10 for AML patients
compared to controls (P = 0.001).
CONCLUSIONS: The present study refers that AML patients were associated with high concentration
of IL‑6 and IL‑10 in comparing to the control group.

Abstract:
BACKGROUND: B‑chronic lymphocytic leukemia (CLL) is a monoclonal malignancy characterized
by an accumulation of small mature‑looking B lymphocytes in the blood, bone marrow, and other
tissues. It is typically characterized by CD5+, CD23+, CD22−, and CD79b−, with weak expression
of surface immunoglobulin (Ig).
OBJECTIVES: The aim of the study was to assess the expression of IgM and IgD heavy chain by
flow cytometry in untreated newly diagnosed B‑cell CLL and correlate the heavy chain isotopes
expression with CD38 expression.
MATERIALS AND METHODS: A prospective cross‑sectional study was conducted on thirty patients
with new diagnosis of B‑CLL. The study was conducted at nursing home teaching laboratory in
medical city hospital in Baghdad for the period from November 2016 to March 2017. Five milliliter of
venous blood in ethylenediaminetetraacetic acid was collected from thirty patients for detection of
expression of IgM, IgD, and CD38 by flow cytometry. The patients were randomly selected regarding
the age, sex, and stage of the disease.
RESULTS: The mean age of all included patients was (61.73 ± 6.92) with more disease predominant
in male than female. The most common presenting feature of the patients was lymphadenopathy
found in 16 patients (43%). Regarding staging system, six (20%) patients were in with Binet Stage C
and five patients (17%) were in modified Rai Stage 4. CD38 and IgM expression showed a significant
relation to hemoglobin and platelets (P < 0.05). There was a significant positive correlation between
IgM and CD38 while it was negative between IgD and CD38.
CONCLUSIONS: The current study showed that the expression of CD38 had a significant correlation
with IgM expression as well as there was positive correlation with the stage of the disease which
may point out to inferior prognosis for those patients with CLL.

Abstract:
BACKGROUND: Cyproheptadine hydrochloride (HCl) is antihistaminic drug which used widely in
our country as an appetizer and for weight gain especially for low weight children.
OBJECTIVE: The aims of this study were to assess the effects of cyproheptadine HCl on blood picture
including white blood cells count, lymphocytes count, and its effect on the level of different cytokines.
MATERIALS AND METHODS: This is an experimental study conducted at Biotechnology Research
Center Laboratory in Alnahrain University from November 2016 to April 2017. It included five groups
of albino male mice, these groups were treated separately with four doses of the cyproheptadine drug
and fifth as control group; the doses were selected according to the British National Formulary (BNF)
2010 calculated on the base of mice/human deference’s in body weight: These are (0.065, 0.092,
0.120, 0.24) mg/mice/day, respectively, with fifth untreated mice group considered as control.
RESULTS: The untreated mice (control) lymphocyte count was (4000) cell/ml and the total
lymphocytes count increased up to (7014) cell/ml than the normal leading changes in interleukins (ILs)
level in different manner, such as decreasing in both IL‑6 and IL‑10 levels with increasing in IL‑12
level and no change in IL‑4 level.
CONCLUSION: The current study showed that cyproheptadine HCl may have unwanted side
effects, and its abuse may lead to disturbances in white blood cell especially lymphocyte which in
turn will affect the immunity of persons taking it, especially in children, since the immune system
modulates ILs secretion to face the irritability of drug behavior, that will lead abnormalities in human
immune system.

Abstract:
Hemostatic abnormalities include both bleeding and thrombosis disorders. Adherence to most
common guidelines for the diagnosis of thrombophilia is recommended especially in some developing
countries. High level of orientation to thrombophilic disorders needs wide spectrum of knowledge
about the causes, primary or secondary, investigations to most common risk factors, selecting
candidates to investigations, in addition to covering the possibility of multifactorial background of
disease. Limited data are available that focus on the thrombophilic disorders with imperfect diagnostic
cooperation between clinical and laboratory aspects to reach the full picture of these hemostatic
abnormalities. In this short review of literature, we considered the most important publications that
assessed the inherited thrombophilia at levels of presentation, diagnosis, and management with
focus on the practical side. The aim of this review is to summarize the most important aspects of
the thrombophilia presentation, inherited causes, indications for testing, and investigations required
for thrombophilic patients.

Abstract:
BACKGROUND: Providing safe blood for transfusion is a responsibility of every blood bank. Screening
for transfusion‑transmissible infections (TTI) is one of the ways to ensure safety of blood and its
products. Prevalence of TTI varies in different countries. It is low in developed countries whereas it
is higher in developing countries.
AIMS AND OBJECTIVES: This study was carried out to access percentage of blood collected from
the first‑time voluntary blood donors (VBD) and family/replacement donors (RD) and to access safety
of RD by comparing seroprevalence of TTI among voluntary and RD.
MATERIALS AND METHODS: Over 1 year, donors were studied for the type of donation (voluntary
or replacement) made at our blood bank. All donors were screened for human immunodeficiency
virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), syphilis, and malaria. Comparison of
the prevalence of TTI among voluntary and RD was done by entering data into Microsoft Excel 2007
software and using Chi‑square tests.
RESULTS: Out of total 850 first‑time donors, voluntary donors were 109 (12.82%) and RD were
741 (87.18%). Overall seroprevalence of HIV, HBV, HCV, syphilis, and malaria was 0, 23 (2.70%),
12 (1.41%), 7 (0.82%), and 0, respectively. Prevalence of TTI among voluntary donors was very low. All
donors were seronegative HIV and malaria. Prevalence of HBV, HCV, and syphilis was higher in RD.
CONCLUSION: Data highlight that RD contributed major source of blood supply in hospital‑based
blood transfusion services and the prevalence of TTI was higher among them in comparison to
first‑time voluntary donors. Thus, efforts should be made to increase the number of VBD.

Abstract:
BACKGROUND: Hemophilia is a sex‑linked bleeding disorder. Affected patients suffer spontaneous
or post-traumatic bleeding into various sites of the body, mainly into joints, depending on the level
of coagulation factor deficiency.
AIMS: This descriptive study is designed to assess the prevalence and extent of arthropathy and
evaluate the functional status of hemophiliacs in Erbil, Northern Iraq.
SETTINGS AND DESIGN: A descriptive study of all registered hemophiliacs at Nanakali
Hemato‑Oncology Teaching Centre, Erbil, Iraq.
PATIENTS AND METHODS: Over 15 months (October 2015 to February 2017), a total of 133
hemophilia patients were studied. Their hospital records were used to retrieve clinical and laboratory
data, mainly their coagulation profile. All patients were clinically examined at the daycare center;
plain radiography was used to evaluate the degree of joint damage based on Petterson score. The
magnitude of joint disease was assessed, and patients’ functional status was evaluated depending
on Functional Independence Score in Hemophilia (FISH).
STATISTICAL ANALYSIS USED: Statistical analysis used MS Excel 2010.
RESULTS: Hemophiliacs mean age was 12.9 years. Patients with severe hemophilia presented earlier
and had more bleeding episodes. At least one bout of hemarthrosis was recorded in 103/133 patients
during the course of their disease with knee joint most frequently involved (in eighty patients) followed
by elbow, ankle, wrist, and shoulder. The Petterson score related significantly to age of the patient,
number of bleeds, and severity of hemophilia. Majority, 67%, of hemophiliacs found to have the
limitation of movement. FISH score significantly related with factor activity level. Functional disability
was encountered in 9.7% of cases; majority had severe hemophilia.
CONCLUSIONS: The incidence and severity of joint bleeding and functional disability were high.
The FISH and Pettersson scoring systems are very useful tools in assessing patients with hemophilic
arthropathy.

Abstract:
INTRODUCTION: Increasing demand of platelet transfusions for patients has led to a trend in the
increased use of automated blood collections. These share many of the same reactions and injuries
seen with pooled platelets obtained from whole blood donation but also have unique complications.
AIMS AND OBJECTIVES: To study the adverse events (AEs) of plateletpheresis procedure and
their relationship with donor and plateletpheresis procedure session profiles.
MATERIALS AND METHODS: This is a retrospective observational study conducted from January
2016 to December 2016. A two-hundred and thirteen (213) plateletpheresis procedures were
performed after taking informed and written consent from the donor. All the donors were male and
selected according to the guidelines laid down by Director General of Health Services. The AEs were
classified into donor related, kit/equipment related and technique related.
RESULTS: A total of 13 AEs were noted; of which, 8 (61.53 %) events were associated with donors,
3 (23.07 %) were owed to fault in kit/equipment and 2 (15.384 %) were due to technical aberrations.
Donor related AEs included vascular injuries [n = 3 (1.40%)], vasovagal reactions [n = 2 (0.938%)]
and perioral tingling sensation [n = 3 (1.40%)]. Technique related AEs [n = 2 (0.938%)] and kit/
equipment related AEs [n = 3 (1.40%)] were due to faulty technique and defective kits respectively.
CONCLUSION: Apheresis donations performed on cell separators are safe. Meticulous donor
vigilance, superior technical personnel training and experienced transfusion medicine specialist’s
supervision will make donor’s experience more pleasant.

Abstract:
BACKGROUND: Thalassemia is the most common genetic disorders worldwide, widely spread
throughout the Mediterranean region including Iraq. One effective method to reduce incidence of
thalassemias and sickle cell disease is premarital screening.
OBJECTIVE: The aim of this study was to determine the prevalence of β‑thalassemia trait and other
hemoglobinopathies among subjects attending the premarital screening center in Erbil.
MATERIALS AND METHODS: Over a period of 1 year, 6224 couples were screened for
hemoglobinopathies. Screened subjects were categorized according to the result of complete
blood count, serum ferritin, and hemoglobin (Hb) electrophoresis into six groups, namely, normal,
β‑thalassemia carriers, α‑thalassemia carriers, sickle cell carriers, Hb‑H (HbH) disease, and iron
deficiency anemia.
RESULTS: The prevalence of β‑thalassemia trait was 6.94% (864/12448) with nearly equal
proportions between male and female (male to female ratio = 1:1.1). HbH disease and sickle cell
trait were less common. Iron deficiency anemia was reported in 52 subjects (0.4%).
CONCLUSION: We found a relatively high prevalence rate of heterozygous β‑thalassemia among the
studied sample in comparison to prevalence figures from reports in the nearby geographic locations.

Abstract:
BACKGROUND: Immunophenotyping improves both accuracy and reproducibility of acute leukemia
classification and is considered, particularly useful for identifying acute myeloid leukemia (AML) with
lymphoid marker expression. The incidence of the aberrant phenotypes in AML is still controversial;
incidences as high as 88% have been reported.
OBJECTIVES: To evaluate the occurrence of aberrant lymphoid phenotypes and to correlate their
presence with various French‑American‑British classification (FAB subtypes), 202 cases of newly
diagnosed AML were analyzed for lymphoid markers CD1a, CD2, CD3, CD4, CD5, CD7, CD8,
CD10, CD19, CD20, and CD79a.
MATERIALS AND METHODS: Whole blood or bone marrow aspirate of 202 patients with de novo
AML was collected in ethylenediaminetetraacetic acid tube and analyzed by flow cytometry using a
large panel of fluorochrome‑labeled monoclonal antibodies. Identification of blast cells was performed
using forward scatter versus side scatter (SSC) parameters and CD45 intensity versus SSC dot plots.
An antigen was considered positively expressed when at least 20% of the gated cells expressed
that antigen.
RESULTS: Eighty‑five patients (42%) with de novo AML expressed lymphoid‑associated antigens.
All AML subtypes demonstrated lymphoid‑associated antigens except M7. T‑cell aberrancy was
the most common comprising 32.2% of the total aberrancy. The most frequently lymphoid antigen
aberrantly expressed was CD7 (25.7%), followed by CD4 (22.4%) and CD19 (7.9%).
CONCLUSION: A large number of AML cases showed aberrant lymphoid phenotypes. These lymphoid
phenotypes might be associated with different leukemia subtypes. T‑cell markers are more common
than B‑cell markers. CD7 was the most common lymphoid marker aberrantly expressed in AML.

Abstract:
BACKGROUND: Anemia in pregnancy has different adverse effects on pregnancy outcome, and
iron deficiency anemia (IDA) is the most common cause of anemia during pregnancy. Recent studies
have suggested an association between Helicobacter pylori and IDA during pregnancy.
OBJECTIVE: The aim of this study was to evaluate the impact of H. pylori infection on IDA in pregnancy.
PATIENTS AND METHODS: This was a case–control study carried out at Al‑Yarmouk Teaching
Hospital between January 1 and August 1, 2016. The study included 100 pregnant women divided
into two groups: control group with normal hemoglobin (Hb) and a study group with IDA. Both groups
were subjected to H. Pylori test.
RESULTS: The mean Hb level of the patients was 9.4 ± 0.8 g/dl. Fifty cases had an Hb
level <11 g/dl and fifty cases with Hb ≥11 gm/dl. Thirty‑two percentage of the study group were
seropositive for anti‑H. pylori IgA compared to 4% of the control group, and this difference was
statistically significant at P < 0.001.
CONCLUSION: There was a positive correlation between IDA during pregnancy and H. pylori‑positive
cases.