Iraqi Journal of Hematology

BACKGROUND: Myelofibrosis (MF) is largely documented by an abnormal cytokine expression, which in turn could
contribute to bone marrow fibrosis, angiogenesis, and constitutional symptoms. To gain additional pathogenetic
insight regarding cytokine phenotype correlations in MF, this study estimated the level of interleukin‑10 (IL‑10)
abnormality and Janus kinase (JAK2 V617F) mutation in primary MF.
OBJECTIVE: The objective of this study was to assess serum IL‑10 level and it’s relation with the presence of
JAK2 V617F mutation in patients with MF.
MATERIALS AND METHODS: JAK2 V617F mutation detection was performed in 32 patients with MF using
amplification refractory mutation screening‑polymerase chain reaction. IL‑10 level was estimated in 36 patients
with MF using enzyme‑linked immunosorbent assay technique compared to 27 healthy controls who were
enrolled for comparison.
RESULTS: The study showed higher significant (P ≤ 0.002) increase of IL‑10 in patients with MF with cutoff
value ≥8.9510 pg/ml and area under the curve value of 0.749 (P < 0.001) and also in patients with serum level
of IL‑10 more than 13.6 pg/ml characterized with significant lower white blood cell count, nonsignificant difference
with lower hemoglobin level, normal platelet count, and smaller size splenomegaly. About 59% of the studied
primary MF (PMF) patients had JAK2 positive, 63% of them were male. There was no significant correlation
between IL‑10 and JAK2.
CONCLUSION: JAK2 mutation and IL‑10 as anti‑inflammatory cytokines may play a role in the pathogenesis and
hematological presentation of patients with PMF. High IL‑10 level may predict good prognosis in patients with PMF.

Abstract:
BACKGROUND: Retinal vein occlusion is the most common retinal vascular disorder after diabetic retinopathy
with several ocular and systemic disorders associated with retinal veins thrombosis. Factor V Leiden (FVL)
mutation as part of inherited thrombophilia may associated with retinal vein thrombosis.
OBJECTIVES: Determine the presence of FVL mutation in a set of Iraqi patients with retinal vein thrombosis
and evaluate its role in the etiology of thrombosis in those patients.
PATIENTS, MATERIALS AND METHODS: A case–control study conducted for 6 months, a total number of
69 patients who were diagnosed with retinal vein thrombosis while attending ophthalmology outpatient clinic in
Diwania city in Iraq. Only sixty patients were eligible for the study. From each patient, venous blood was withdrawn
for complete blood count, blood film, erythrocyte sedimentation rate, kaolin clotting time, anticardiolipin antibodies,
antinuclear antibody, thyroid‑stimulating hormone, renal function test, random blood sugar, and serum cholesterol
in addition to determine the presence of FVL mutation by polymerase chain reaction (PCR)‑restriction fragment
length polymorphism. For 84 individuals of control group, only the presence of FVL mutation by PCR was done.
RESULTS: Sixty out of 69 patients with retinal vein thrombosis were eligible for the study. There were a total of
34 males and 26 females with a mean age of 49.1 ± 2.03 years with no significant statistical differences in mean
age and sex between the patients and the control groups. The proportion of patients with FVL mutation was
higher than that of control subjects, 21.7% versus 8.3% (P = 0.023). FVL mutation in patients group showing a
significant risk factor to develop retinal vein thrombosis than control group (odd ratio: 3.043).
CONCLUSIONS: FVL plays a role in etiology of retinal vein thrombosis and measurement of this mutation with
proper prophylaxis may be useful in prevention of venous thrombosis.

BACKGROUND: β‑thalassemia trait (β‑TT) is an important differential diagnosis of iron deficiency anemia (IDA).
It is important to distinguish between the above conditions to avoid unnecessary iron therapy. IDA and β‑TT are
the two most common causes of microcytic hypochromic anemia. Red blood cells (RBCs) indices are a simple,
easy, and cost‑effective method to get a primary and valuable information regarding the diagnosis of IDA and β‑TT.
OBJECTIVES: This study was focused on the comparison of RBC indices behavior: hemoglobin (Hb),
hematocrit (Hct), RBC count, mean cell volume (MCV), mean cell hemoglobin (MCH), MCH concentration (MCHC),
and red cell distribution width (RDW) in IDA and β‑TT.
PATIENTS AND METHODS: Fifty subjects with IDA (12 males and 38 females, age range: 18–65 years) and
fifty subjects with β‑TT (twenty male and thirty females with age range: 17–66 years) were chosen. Both groups
were investigated for RBC indices by automated hematology analyzer.
RESULTS: RBC count, Hb, and Hct were significantly lower with (P < 0.001) in IDA subjects than in β‑TT
subjects. MCH and MCHC were significantly lower with (P = 0.01 and 0.001, respectively) in IDA subjects than
in β‑TT subjects. RDW was significantly higher with (P < 0.001) in IDA subjects than in β‑TT subjects. There is
no significant difference with (P = 0.2) regarding MCV between IDA subjects and β‑TT subjects.
CONCLUSION: The study showed that RBC count, Hb, Hct, MCH, and MCHC were significantly lower in IDA
subjects than in β‑TT subjects, whereas RDW was significantly higher in IDA subjects than in β‑TT subjects.
There was no significant difference regarding MCV between IDA subjects and β‑TT subjects.

Abstract:
BACKGROUND: Von Willebrand disease (vWD) is a common, inherited hemorrhagic disorder caused by a
deficiency or dysfunction of the protein von Willebrand factor (vWF).
OBJECTIVES: The aim of this study is to assess the diagnosis and treatment of vWD in a single Iraqi teaching
hospital.
PATIENTS AND METHODS: This descriptive study was conducted on 778 patients with bleeding tendency,
107 patients were diagnosed to have vWD, and from the first of October 2013 to the first of August 2015.
The diagnosis of the disease was made by a wide spectrum of characteristics including family history, clinical
manifestations, and laboratory tests.
RESULTS: The common manifestations of the disease at the time of the diagnosis were epistaxis (39.2%), gum
bleeding (24.2%), and menorrhagia (23.4%) in female patients. The age of patients at time of presentation was
between 1 and 10 years. Family history was positive in most patients. Hepatitis C was rare in the patients after
cryoprecipitate administration.
CONCLUSIONS: It is a common inherited hemorrhagic disease in Iraq, mostly presented as minor bleeding
involving mainly mucocutaneous regions which appears at an early childhood with positive family history in most
cases.

BACKGROUND: Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in the Western world.
The zeta‑chain‑associated protein (ZAP‑70) an intracellular tyrosine kinase which play an important role in T‑cell
receptor signaling, natural killer cell activation, and early B‑cell development. Interleukin‑10 (IL‑10) production
has strong immunosuppressive effects through inhibition of Th1 type cytokines. IL‑6 is a pleiotropic cytokine
produced by a variety of cell types, including normal hematopoietic cells, and lymphocytes.
OBJECTIVES: The objective of this study is to assess the level of ZAP‑70, IL‑10, and IL‑6 in CLL and to correlate
these levels with prognosis.
MATERIALS AND METHODS: A prospective cohort study carried out at the National Center of Hematology from
October 2013 to September 2015. Eighteen patients with newly diagnosis of CLL compared to 19 apparently
healthy controls were also involved in this study. ZAP‑70 was measured by while IL‑10 and IL‑6 were measured
using serological methods including the enzyme‑linked immunosorbent assay.
RESULTS: ZAP‑70 range between (24% and 90%) with a mean of 46.89 ± 19.15, two patients out of 18 were
negative (<24%) for ZAP‑70 as compared with control. The levels of IL‑6 in the serum of untreated patients with
CLL were increased in compared with healthy control (2.53 ± 1.98), ranged between (0.12 and 6.94) pg/ml. The
range of the IL‑10 expression of the untreated CLL patients was between (the lowest positive value (212 pg/ml)
and which is the highest positive value (987 pg/ml) with a mean 614 ± 301 pg/ml, with all the morphologically
diagnosed CLL cases show positive expression for IL‑10.
CONCLUSION: ZAP‑70 level was higher in CLL patients than control and immunochemotherapy can normalize
this which indicated good response to treatment. On the other hand, IL6 and IL10 were also higher in patients
with CLL but not affected by therapy.

Abstract:
BACKGROUND: Leukemic stem cells (LSCs) are thought to originate either from normal hematopoietic stem cells
or from more differentiated progenitor cells. LSCs are capable of self‑renewal, proliferation, and differentiation
into malignant blasts.
OBJECTIVE: To evaluate the expression of the LSC markers CD96 and CD123 in de novo acute myeloid
leukemia (AML) patients, and to explore the relationship between those markers and response to induction
therapy and prognostic factors in AML.
MATERIALS AND METHODS: A cross‑sectional study was conducted on 30 adults with newly diagnosed AML
patients were prospectively tested for the expression of CD96 and CD123 using four‑color flow cytometer at the
time of diagnosis and re‑evaluated at day 28 from the start of chemotherapy for the response to 3 + 7 induction
therapy regimen.
RESULTS: Eight cases (26.7%) expressed CD96, and 12 cases (40%) expressed CD123; all the CD96 positive
cases were also CD123 positive, however, four cases among the CD123 positive patients did not express CD96.
CD96 and CD123 were expressed more on blast cells in the cases of M5 French–American–British subtype,
whereas the least expression was in M3. Among the eight cases with CD96+ expression, only (37.5%) acquired
CR, whereas cases without CD96 expression, (77.3%) acquired CR. Among the 12 cases with CD123+ expression,
only (33.3%) acquired CR, while cases without CD123 expression, (88.9%) acquired CR.
CONCLUSION: The expressions of CD96 and CD123 were associated with a higher total white blood cell count
and bone marrow blast cells at presentation, and a lower response rate to the induction therapy.

Abstract:
BACKGROUND: In the last decade, tremendous changes occurred in the treatment and follow‑up of the patients
with chronic myeloid leukemia (CML), with continuous update in the close molecular monitoring of treatment for
the presence of minimal residual disease.
OBJECTIVES: The objective of this study was to evaluate the molecular monitoring of patients with CML on
tyrosine kinase inhibitor (TKI) treatment and categorization of those patients according to the European Leukemia
Net (ELN) guidelines.
MATERIALS AND METHODS: This observational cross‑sectional study was conducted among all patients with
CML registered in Oncology and Hematology Centers in Middle Euphrates of Iraq including 244 patients from April
2013 to April 2016. Eligible patients were 199 cases while 45 cases were excluded from the study. Venous blood
in ethylenediaminetetraacetic acid was collected with each time of molecular monitoring to assess the level of
messenger RNA of breakpoint cluster region-Abelson (BCR‑ABL) by quantitative reverse transcriptase‑polymerase
chain reaction (RT‑PCR) (Cepheid, Gene Xpert Diagnostic System).
RESULTS: Most of the patients were in young adult age group with disease predominance more in females
than males. Majority of the patients (72%) achieved optimal response after 12 months of treatment according to
the ELN guidelines and 28% showed primary resistance to TKI. Some patients with optimal response (9%) will
develop secondary resistance to treatment.
CONCLUSION: Most of our patients achieved major molecular response after 12 months of treatment with
TKI according to the ELN guidelines that reflect proper management and regular follow‑up of the patients by
quantitative RT‑PCR for the detection of BCR‑ABL level.

Abstract:
BACKGROUND: Synthetic drugs are created using chemicals rather than natural ingredients. One reason that
synthetic drugs are extremely dangerous is that buyers do not know what chemicals they are ingesting. Histamine
in the body can produce symptoms of sneezing, itching, watery eyes, and runny nose. Cyproheptadine (periactin)
an antihistamine is used to treat all these symptoms of allergies by reduces the natural chemical histamine, but
it has different side effects which include: confusion, hallucinations, unusual thoughts or behavior, and seizure
(convulsions).
OBJECTIVE: The aim of this study is to prove the scope of danger from cyproheptadine abuse on lymphocyte
cells of male mice treated with child dose, maximum dose, and adult dose that may affect blood picture and their
cytotoxic effect by determination of micronucleus (MN) formation in the cells of mice bone marrow.
MATERIALS AND METHODS: In the current study, a method was used for determination of total and absolute
counts of white blood cells and find the frequency of MN formation in three groups of albino male mice treated
with three equivalent doses of cyproheptadine: child dose, adult dose, and maximum adult dose (0.065, 0.092,
and 0.12 mg/kg) respectively.
RESULTS: The study showed that cyproheptadine decreases total leukocyte count in adult and child dose in
comparison to mice blank group that had not get the drug; also, the frequency of MN increases significantly after
treated mice with cyproheptadine drug in comparison with negative control.
CONCLUSION: More studies are necessary to elucidate the relationship between cytotoxic, genotoxic, and
apoptotic effects and to make a possible risk assessment in patients receiving therapy with this drug.

Despite being immune deficient, chronic lymphocytic leukemia (CLL) patients have an increased incidence of
autoimmune cytopenias secondary to autoantibody formation. These are: warm autoimmune hemolytic anemia;
idiopathic thrombocytopenia; pure red cell aplasia (PRCA), and In this case report, we describe a patient with
CLL who developed severe anemia requiring frequent red cell transfusion after the third cycle of chemotherapy.
Blood film showed no evidence of hemolysis and absolute reticulocytopenia. Bone marrow showed erythroid
hypoplasia and residual interstitial infiltrate of CLL. The diagnosis of CLL‑induced PRCA was made, and the
patient showed a prompt and dramatic response to treatment with cyclosporine.

Abstract:
BACKGROUND: Emergency department evaluation of young febrile children often includes measurement of
white blood cell (WBC) count. Although a high WBC count is associated with an increased likelihood of infection,
the clinical significance of extreme leukocytosis (EL) (a WBC count of ≥25,000/mm3), has not been well studied.
OBJECTIVE: The aim of this study is to study the correlation between the level of WBC and the cause of fever
in febrile children and to assess if WBC level helpful in predicting the seriousness of febrile illness.
PATIENTS AND METHODS: A cross‑sectional case series study conducted over 5 months from August 01 to
December 31, 2015, in the emergency department at child central teaching hospital in Baghdad city in Iraq. The
study was evaluating children aged 3–36 months admitted to the emergency department for fever. WBC count
was done either manually or a complete blood count by automated hematologic analyzer.
RESULTS: Of those 129 febrile children were enrolled in this study, 42 patients with EL were identified and
compared with 87 patients with moderate leukocytosis (ML). Pneumonia was the only diagnosis found to be
significantly higher in EL group 17 cases (40.5%) versus 15 cases (17.2%) in ML group with P value (0.004).
Meningitis was higher in patient with ML with P value (0.03). Finally, EL was associated with higher rates of
admission to hospital (P < 0.036).
CONCLUSIONS: The presence of EL indicates a higher risk of having pneumonia. The degree of
leukocytosis (extreme or moderate) does not affect the rates of serious bacterial infection.