FUBP3 regulates chronic myeloid leukaemia progression through PRC2 complex regulated PAK1-ERK signalling

The development of resistance and heterogeneity in differential response towards tyrosine kinase inhibitors (TKI) in chronic myeloid leukaemia (CML) treatment has led to the exploration of factors independent of the Philadelphia chromosome. Among these are the association of deletions of genes on derivative (der) 9 chromosome with adverse outcomes in CML patients. However, the functional role of genes near the breakpoint on der (9) in CML prognosis and progression remains largely unexplored. Copy number variation and mRNA expression were evaluated for five genes located near the breakpoint on der (9). Our data showed a significant association between microdeletions of the FUBP3 gene and its reduced expression with poor prognostic markers and adverse response outcomes in CML patients. Further investigation using K562 cells showed that the decrease in FUBP3 protein was associated with an increase in proliferation and survival due to activation of the MAPK-ERK pathway. We have established a novel direct interaction of FUBP3 protein and PRC2 complex in the regulation of ERK signalling via PAK1. Our findings demonstrate the role of the FUBP3 gene located on der (9) in poor response and progression in CML with the identification of additional druggable targets such as PAK1 in improving response outcomes in CML patients.

Spontaneous Epidural Hematoma in Sickle Cell Crisis: A Case Report

Epidural hematoma (EDH) classically occurs secondary to trauma. Spontaneous EDH is uncommon and can be a rare complication of sickle cell disease (SCD). We report the case of a 20-year-old Indian male with sickle cell anemia, who presented with a sickling bony crisis and suffered a non-traumatic EDH within 24 hours of admission.

A 20-year-old male presented with generalized body pain, suggestive of a sickling bony crisis. He was promptly admitted and received standard treatment for the same. The next day, he developed severe right-sided headache, associated with orbital pain, decreased movements on the right side, and altered sensorium. He had a Glasgow coma scale score of 8/15, and reduced power of the right upper limb and lower limb. Computed tomography (CT) and magnetic resonance imaging (MRI) of the brain showed a left-sided large parieto-temporal epidural hematoma with midline shift and mass effect. He underwent emergency decompressive craniotomy and evacuation of the hematoma, following which he recovered well, with no residual deficits.

Spontaneous EDH is being increasingly reported in SCD. Possible mechanisms include skull bone infarction, altered skull bone anatomy due to extramedullary hematopoiesis, and venous congestion due to sluggish blood flow in diploic veins. In our patient, altered skull anatomy appeared to be the causative mechanism. Early identification of EDH and aggressive neurosurgical management is crucial to survival and a good prognosis.

Rare Complication of a Rare Malignancy: Case Report of Cardiac Amyloidosis Secondary to Waldenstrom Macroglobulinemia

Cardiac amyloidosis is a rare disorder caused by the myocardial deposition of abnormal fibrils. A 52-year-old man was referred to our center with clinical features of heart failure, after cardiac magnetic resonance imaging showed restrictive cardiomyopathy. Abdominal fat pad biopsy showed features of amyloidosis, and after hematological workup, he was diagnosed with Waldenstrom macroglobulinemia (WM). He was initiated on a rituximab-based chemotherapy regimen, and his cardiac function was assessed serially. Because of non-response, he was switched to a bortezomib-based regimen. Unfortunately, three days into this regimen, the patient died. WM is a rare plasma cell dyscrasia with a nonspecific presentation. It uncommonly presents with sequelae of amyloidosis–the IgM subtype of amyloid-light chain (AL) amyloidosis. Diagnostic delays are common, contributing to an already poor prognosis. Amyloidosis in WM requires urgent treatment – clonal chemotherapy, and supportive cardiac care in heart involvement. Bortezomib-based regimens are commonly recommended, with diuretics as the mainstay for cardiac treatment. However, in most advanced cases, the prognosis is poor; thus, a high degree of suspicion is necessary for early diagnosis. This case illustrates the possible presentation of cardiac amyloidosis as a rare malignancy.

Chronic Pelvic Osteomyelitis: Case Report of a Rare Complication of Bone Marrow Biopsy

Osteomyelitis commonly involves the long bones, with pelvic involvement uncommon. We report the case of a 50-year-old male who, following a bone marrow biopsy that diagnosed him with non-Hodgkin’s lymphoma, had persistent complaints of fever, swelling, and pain over the biopsy site. Pus cultures revealed growth of methicillin-resistant Staphylococcus aureus (MRSA), with computed tomography and magnetic resonance imaging of the pelvis revealing features of osteomyelitis of the right ilium. He was managed conservatively with antibiotics. On the last follow-up, he had just recovered from another flare of the infection. Bone marrow biopsy is a common tool in the hematologist's inventory. It is quite safe, with complications reported in less than 0.1% of all cases. Osteomyelitis of the pelvis following this is exceedingly rare; to our knowledge, only two prior such cases have been reported. Pelvic osteomyelitis is characterized by poorly defined hip pain, limited range of motion, and difficulty with ambulation. In case of intractable hip or buttock pain following a bone marrow biopsy, osteomyelitis of the pelvis must be considered in the differential diagnosis, and appropriate management must be begun. A multidisciplinary approach is required, with surgical debridement and appropriate antibiotics. 

Autoimmune Hemolytic Anaemias in Pregnancy: Experience in a Tertiary Care Hospital in South India

Background

Autoimmune hemolytic anaemia is very rare and there is limited data regarding their pregnancy outcomes. Hence we aimed to study the maternal and perinatal outcomes in pregnancies with autoimmune hemolytic anaemias (AIHA).

Methods

A retrospective descriptive study of pregnant women with AIHA, who delivered at SJMCH between January 2011 and January 2016 was carried out. Their antenatal and labour records were reviewed and demographic details noted.The primary outcome measures studied were-the prevalence of AIHA, gestational age at delivery, antepartum, intrapartum and postpartum complications, mode of delivery and requirement of transfusion of blood and blood products. The secondary outcome measures studied included neonatal outcomes such as low birth weight, intrauterine growth restriction and need for intensive care. The data is presented as descriptive statistics, including means and percentage.

Results

The prevalence of AIHA was (18/12,420) 0.14%. The mean gestational age at delivery was 34 weeks; 100%, 77% and 50% had antenatal, intra partum or postpartum complications, respectively. 44% had preeclampsia, 38% intrauterine growth restriction and 16% preterm labour. 83% required additional drugs for treatment of AIHA.72% had vaginal delivery; 28% had caesarean delivery; 33% were transfused antenatally and 22% postnatally; 50% of the babies were preterm and required intensive care, 66% had low birth weight. There was no maternal mortality.

Conclusion

Multidisciplinary approach, early diagnosis and detection of autoimmune hemolytic anaemia and complications, good antenatal care, judicious transfusions and delivery at tertiary care centre are the keys to successful outcomes.

Elevated, combined serum free light chain levels and increased mortality: a 5-year follow-up, UK study

AIMS

Abnormal serum free light chain (FLC) ratios are diagnostically important in almost all plasma cell disorders. However, absolute increases in polyclonal FLC levels are often discarded as inconsequential. Here we report an association between increased combined polyclonal FLC (cFLC: FLCκ plus FLCλ) concentrations and mortality.

METHODS

723 patients sent for 30 routine haematological assessments were enrolled. Patients with a confirmed monoclonal gammopathy were removed. The remaining 527 patients were followed up for up to 4.5 years. Statistical analysis was performed using SPSS (V.19).

RESULTS

During follow-up, there were 99 deaths (18.8%). Kaplan-Meier survival analysis revealed 29% of these deaths occurred within the first 100 days (N=29). Multivariate analysis identified only cFLC >65 mg/l, albumin <33 g/l and  estimated glomerular filtration rate <30 ml/min/1.73 m(2) to be independently associated with mortality within 100 days and 4.5 years with, cFLC having the highest HR of 7.1. A simple risk stratification model based only on albumin and cFLC identified 86% mortality within 100 days and 62% over 4.5 years.

CONCLUSIONS

Elevated cFLC is significantly associated with increased mortality and with albumin can be used to identify patients at risk of mortality at 4.5 years with high-risk patients detected within 100 days.