Turkish Journal of Hematology Volume: 31 - Issue: 4

Volume 31 Issue 4 December 2014 40 TL
ISSN 1300-7777
Review Article
Diagnosis of Invasive Fungal Diseases in Hematological Malignancies: A Critical Review of
Evidence and Turkish Expert Opinion (TEO-2)
Sevtap Arıkan Akdağlı, et al.; Ankara, Bursa, Kayseri, İstanbul, Turkey
Research Articles
The Relationship between P-Selectin Polymorphisms and Thrombosis in Antiphospholipid Syndrome:
A Pilot Case-Control Study
Nilüfer Alpay, et al.; İstanbul, Turkey
Serum Bcl-2 Levels in Patients with β-Thalassemia Minor: A Pilot Study
İrfan Yavaşoğlu, et al.; Aydın, Turkey
Duffy and Kidd Genotyping Facilitates Pretransfusion Testing in Patients Undergoing Long-Term
Transfusion Therapy
Diana Remeikiene, et al.; Kaunas, Lithuania
Bone-Specific Alkaline Phosphatase Levels among Patients with Multiple Myeloma Receiving Various
Therapy Options
Güven Çetin, et al.; İstanbul, Diyarbakır, Turkey
The Relationship of T Helper-2 Pathway Components Interleukin-4, Interleukin-10, Immunoglobulin E, and
Eosinophils with Prognostic Markers in Non-Hodgkin Lymphoma: A Case-Control Study
Nil Güler, et al.; Samsun, Turkey
The Association of HLA Class 1 and Class 2 Antigens with Multiple Myeloma in Iranian Patients
Arezou Sayad, et al.; Tehran, Iran
New Insights on Iron Study in Myelodysplasia
Noha M. El Husseiny, et al.; Cairo, Egypt
Cover Picture:
Işıl Erdoğan
Winter’s Tale, Abant, Bolu
4

Editor-in-Chief
Aytemiz Gürgey
Ankara, Turkey
Associate Editors
Ayşegül Ünüvar
İstanbul University, İstanbul, Turkey
M. Cem Ar
İstanbul University Cerrahpaşa Faculty of
Medicine, İstanbul, Turkey
Cengiz Beyan
Gülhane Military Medical Academy,
Ankara, Turkey
Hale Ören
Dokuz Eylül University, İzmir, Turkey
İbrahim C. Haznedaroğlu
Hacettepe University, Ankara, Turkey
İlknur Kozanoğlu
Başkent University, Adana, Turkey
Mehmet Ertem
Ankara University, Ankara, Turkey
A. Muzaffer Demir
Trakya University, Edirne, Turkey
Reyhan Diz Küçükkaya
İstanbul Bilim University, İstanbul, Turkey
Assistant Editors
A. Emre Eşkazan
İstanbul University Cerrahpaşa Faculty of
Medicine, İstanbul, Turkey
Ali İrfan Emre Tekgündüz
Dr. A. Yurtaslan Ankara Oncology Training
and Research Hospital, Ankara, Turkey
İnci Alacacıoğlu
Dokuz Eylul University, Ankara, Turkey
Nil Güler
On Dokuz Mayıs University, Samsun, Turkey
Olga Meltem Akay
Osmangazi University, Eskişehir, Turkey
Selami Koçak Toprak
Ankara University, Ankara, Turkey
Şule Ünal
Hacettepe University, Ankara, Turkey
Veysel Sabri Hançer
İstanbul Bilim University, İstanbul, Turkey
Zühre Kaya
Gazi University, Ankara, Turkey
International Review Board
Nejat Akar
Görgün Akpek
Serhan Alkan
Çiğdem Altay
Koen van Besien
Ayhan Çavdar
M.Sıraç Dilber
Ahmet Doğan
Peter Dreger
Thierry Facon
Jawed Fareed
Gösta Gahrton
Dieter Hoelzer
Marilyn Manco-Johnson
Andreas Josting
Emin Kansu
Winfried Kern
Nigel Key
Korgün Koral
Abdullah Kutlar
Luca Malcovati
Robert Marcus
Jean Pierre Marie
Ghulam Mufti
Gerassimos A. Pangalis
Antonio Piga
Ananda Prasad
Jacob M. Rowe
Jens-Ulrich Rüffer
Norbert Schmitz
Orhan Sezer
Anna Sureda
Ayalew Tefferi
Nükhet Tüzüner
Catherine Verfaillie
Srdan Verstovsek
Claudio Viscoli
Past Editors
Erich Frank
Orhan Ulutin
Hamdi Akan
Senior Advisory Board
Yücel Tangün
Osman İlhan
Muhit Özcan
TOBB Economy Technical University Hospital, Ankara, Turkey
Maryland School of Medicine, Baltimore, USA
Cedars-Sinai Medical Center, USA
Ankara, Turkey
Chicago Medical Center University, Chicago, USA
Ankara, Turkey
Karolinska University, Stockholm, Sweden
Mayo Clinic Saint Marys Hospital, USA
Heidelberg University, Heidelberg, Germany
Lille University, Lille, France
Loyola University, Maywood, USA
Karolinska University Hospital, Stockholm, Sweden
Frankfurt University, Frankfurt, Germany
Colorado Health Sciences University, USA
University Hospital Cologne, Cologne, Germany
Hacettepe University, Ankara, Turkey
Albert Ludwigs University, Germany
University of North Carolina School of Medicine, NC, USA
Southwestern Medical Center, Texas, USA
Georgia Health Sciences University, Augusta, USA
Pavia Medical School University, Pavia, Italy
Kings College Hospital, London, UK
Pierre et Marie Curie University, Paris, France
King’s Hospital, London, UK
Athens University, Athens, Greece
Torino University, Torino, Italy
Wayne State University School of Medicine, Detroit, USA
Rambam Medical Center, Haifa, Israel
University of Köln, Germany
AK St Georg, Hamburg, Germany
Memorial Şişli Hospital, İstanbul, Turkey
Santa Creu i Sant Pau Hospital, Barcelona, Spain
Mayo Clinic, Rochester, Minnesota, USA
Istanbul Cerrahpaşa University, İstanbul, Turkey
University of Minnesota, Minnesota, USA
The University of Texas MD Anderson Cancer Center, Houston, USA
San Martino University, Genoa, Italy
Language Editor
Leslie Demir
Statistic Editor
Hülya Ellidokuz
Editorial Office
İpek Durusu
Bengü Timoçin
A-I
Publishing
Services
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Contact Information
Editorial Correspondence should be addressed to Dr. Aytemiz Gürgey
Editor-in-Chief
Address: 725. Sok. Görkem Sitesi
Yıldızevler No: 39/2, 06550 Çankaya, Ankara / Turkey
Phone : +90 312 438 14 60
E-mail : agurgey@hacettepe.edu.tr
All other inquiries should be adressed to
TURKISH JOURNAL OF HEMATOLOGY
Address: İlkbahar Mahallesi, Turan Güneş Bulvarı 613. Sk. No:8 06550 Çankaya, Ankara / Turkey
Phone : +90 312 490 98 97
Fax : +90 312 490 98 68
E-mail : info@tjh.com.tr
ISSN: 1300-7777
Turkish Society of Hematology
Teoman Soysal, President
A. Muzaffer Demir, General Secretary
Hale Ören, Vice President
İbrahim C. Haznedaroğlu, Research Secretary
Fahir Özkalemkaş, Treasurer
A. Zahit Bolaman, Member
Mehmet Sönmez, Member
Online Manuscript Submission
http://mc.manuscriptcentral.com/tjh
Web page
www.tjh.com.tr
Owner on behalf of the Turkish Society of Hematology
Türk Hematoloji Derneği adına yayın sahibi
Teoman Soysal
Publishing Manager
Sorumlu Yazı İşleri Müdürü
A. Muzaffer Demir
Management Address
Yayın İdare Adresi
Türk Hematoloji Derneği
İlkbahar Mahallesi, Turan Güneş Bulvarı 613. Sk. No:8 06550
Çankaya, Ankara / Turkey
Publishing House / Yayınevi
Molla Gürani Mah. Kaçamak Sk. No: 21, 34093 Fındıkzade, İstanbul,
Turkey Tel: +90 212 621 99 25 Faks: +90 212 621 99 27
E-posta: info@galenos.com.tr
Baskı: Senk Ofset Matbaacılık Reklam Promosyon ve Tan. Hiz. San.
Dış. Tic. Ltd. Şti. Tel.: +90 212 493 26 26 Topkapı Litros yolu, No: 24,
Zeytinburnu, İstanbul, Turkey
Printing Date / Basım Tarihi
25.11.2014
Cover Picture
Işıl Erdoğan was born in 1982, Turkey.
She is currently working at
İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey.
Üç ayda bir yayımlanan İngilizce süreli yayındır.
International scientific journal published quarterly.
Türk Hematoloji Derneği, 07.10.2008 tarihli ve 6 no’lu kararı ile Turkish Journal of Hematology’nin
Türk Hematoloji Derneği İktisadi İşletmesi tarafından yayınlanmasına karar vermiştir.
A-II

AIMS AND SCOPE
The Turkish Journal of Hematology is published quarterly
(March, June, September, and December) by the Turkish Society
of Hematology. It is an independent, non-profit peer-reviewed
international English-language periodical encompassing subjects
relevant to hematology.
The Editorial Board of The Turkish Journal of Hematology adheres
to the principles of the World Association of Medical Editors
(WAME), International Council of Medical Journal Editors (ICMJE),
Committee on Publication Ethics (COPE), Consolidated Standards
of Reporting Trials (CONSORT) and Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE).
The aim of The Turkish Journal Hematology is to publish original
hematological research of the highest scientific quality and
clinical relevance. Additionally, educational material, reviews on
basic developments, editorial short notes, case reports, images in
hematology, and letters from hematology specialists and clinicians
covering their experience and comments on hematology and related
medical fields as well as social subjects are published.
General practitioners interested in hematology and internal medicine
specialists are among our target audience, and The Turkish Journal
of Hematology aims to publish according to their needs. The Turkish
Journal of Hematology is indexed, as follows:
- PubMed
- PubMed Central
- Science Citation Index Expanded
- EMBASE
- Scopus
- CINAHL
- Gale/Cengage Learning
- EBSCO
- DOAJ
- ProQuest
- Index Copernicus
- Tübitak/Ulakbim Turkish Medical Database
- Turk Medline
Impact Factor: 0.340
Subscription Information
The Turkish Journal of Hematology is sent free-of-charge to members
of Turkish Society of Hematology and libraries in Turkey and
abroad. Hematologists, other medical specialists that are interested
in hematology, and academicians could subscribe for only 40 $ per
printed issue. All published volumes are available in full text free-ofcharge
online at www.tjh.com.tr.
Address: İlkbahar Mah., Turan Güneş Bulvarı, 613 Sok., No: 8,
Çankaya, Ankara, Turkey
Telephone: +90 312 490 98 97
Fax: +90 312 490 98 68
Online Manuscript Submission: http://mc.manuscriptcentral.com/tjh
Web page: www.tjh.com.tr
E-mail: info@tjh.com.tr
Permissions
Requests for permission to reproduce published material should be
sent to the editorial office.
Editor: Professor Dr. Aytemiz Gürgey
Adress: Ilkbahar Mah, Turan Günes Bulvarı, 613 Sok., No: 8,
Çankaya, Ankara, Turkey
Telephone: +90 312 490 98 97
Fax: +90 312 490 98 68
Online Manuscript Submission: http://mc.manuscriptcentral.com/tjh
Web page: www.tjh.com.tr
E-mail: info@tjh.com.tr
Publisher
Galenos Yayinevi
Molla Gürani Mah. Kaçamak Sk. No:21 34093 Fındıkzade-İstanbul
Telephone : 0212 621 99 25
Fax : 0212 621 99 27
info@galenos.com.tr
Instructions for Authors
Instructions for authors are published in the journal and at www.
tjh.com.tr
Material Disclaimer
Authors are responsible for the manuscripts they publish in The
Turkish Journal of Hematology. The editor, editorial board, and
publisher do not accept any responsibility for published manuscripts.
The journal is printed on acid-free paper.
Editorial Policy
Following receipt of each manuscript, a checklist is completed by
the Editorial Assistant. The Editorial Assistant checks that each
manuscript contains all required components and adheres to the
author guidelines, after which time it will be forwarded to the Editor
in Chief. Following the Editor in Chief’s evaluation, each manuscript
is forwarded to the Associate Editor, who in turn assigns reviewers.
Generally, all manuscripts will be reviewed by at least three reviewers
selected by the Associate Editor, based on their relevant expertise.
Associate editor could be assigned as a reviewer along with the
reviewers. After the reviewing process, all manuscripts are evaluated
in the Editorial Board Meeting.
Turkish Journal of Hematology’s editor and Editorial Board
members are active researchers. It is possible that they would desire
to submit their manuscript to the Turkish Journal of Hematology.
This may be creating a conflict of interest. These manuscripts will
not be evaluated by the submitting editor(s). The review process
will be managed and decisions made by editor-in-chief who will act
independently. In some situation, this process will be overseen by an
outside independent expert in reviewing submissions from editors.
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TURKISH JOURNAL OF HEMATOLOGY
INSTRUCTIONS TO AUTHORS
The Turkish Journal of Hematology accepts invited review articles,
research articles, brief reports, case reports, letters to the editor, and
hematological images that are relevant to the scope of hematology,
on the condition that they have not been previously published
elsewhere. Basic science manuscripts, such as randomized, cohort,
cross-sectional, and case control studies, are given preference. All
manuscripts are subject to editorial revision to ensure they conform
to the style adopted by the journal. There is a single blind kind of
reviewing system.
Manuscripts should be prepared according to ICMJE guidelines
(http://www.icmje.org/). Original manuscripts require a structured
abstract. Label each section of the structured abstract with the
appropriate subheading (Objective, Materials and Methods, Results,
and Conclusion). Case reports require short unstructured abstracts.
Letters to the editor do not require an abstract. Research or project
support should be acknowledged as a footnote on the title page.
Technical and other assistance should be provided on the title page.
Original Manuscripts
Title Page
Title: The title should provide important information regarding the
manuscript’s content. The title must specify that the study is a cohort
study, cross-sectional study, case control study, or randomized study
(i.e. Cao GY, Li KX, Jin PF, Yue XY, Yang C, Hu X. Comparative
bioavailability of ferrous succinate tablet formulations without
correction for baseline circadian changes in iron concentration in
healthy Chinese male subjects: A single-dose, randomized, 2-period
crossover study. Clin Ther. 2011; 33: 2054-2059).
The title page should include the authors’ names, degrees, and
institutional/professional affiliations, a short title, abbreviations,
keywords, financial disclosure statement, and conflict of interest
statement. If a manuscript includes authors from more than one
institution, each author’s name should be followed by a superscript
number that corresponds to their institution, which is listed separately.
Please provide contact information for the corresponding author,
including name, e-mail address, and telephone and fax numbers.
Running Head: The running head should not be more than 40
characters, including spaces, and should be located at the bottom of
the title page.
Word Count: A word count for the manuscript, excluding abstract,
acknowledgments, figure and table legends, and references, should
be provided not exceed 2500 words. The word count for an abstract
should be not exceed 300 words.
Conflict-of-Interest Statement: To prevent potential conflicts of
interest from being overlooked, this statement must be included in
each manuscript. In case there are conflicts of interest, every author
should complete the ICMJE general declaration form, which can be
obtained at: http://www.icmje.org/coi_disclose.pdf.
Abstract and Keywords: The second page should include an abstract
that does not exceed 300 words. For manuscripts sent by authors
in Turkey, a title and abstract in Turkish are also required. As most
readers read the abstract first, it is critically important. Moreover, as
various electronic databases integrate only abstracts into their index,
important findings should be presented in the abstract.
Objective: The abstract should state the objective (the purpose of the
study and hypothesis) and summarize the rationale for the study.
Materials and Methods: Important methods should be written
respectively.
Results: Important findings and results should be provided here.
Conclusion: The study’s new and important findings should be
highlighted and interpreted.
Other types of manuscripts, such as case reports, reviews, perspectives,
and editorials, will be published according to uniform requirements.
Provide 3-10 keywords below the abstract to assist indexers. Use
terms from the Index Medicus Medical Subject Headings List
(for randomized studies a CONSORT abstract should be provided
(http://www.consort-statement.org).
Introduction: The introduction should include an overview of the
relevant literature presented in summary form (one page), and what
ever remains interesting, unique, problematic, relevant, or unknown
about the topic must be specified. The introduction should conclude
with the rationale for the study, its design, and its objective(s).
Materials and Methods: Clearly describe the selection of observational
or experimental participants, such as patients, laboratory animals, and
controls, including inclusion and exclusion criteria and a description
of the source population. Identify the methods and procedures in
sufficient detail to allow other researchers to reproduce your results.
Provide references to established methods (including statistical
methods), provide references to brief modified methods, and provide
the rationale for using them and an evaluation of their limitations.
Identify all drugs and chemicals used, including generic names,
doses, and routes of administration. The section should include only
information that was available at the time the plan or protocol for
the study was devised (http://www.strobe-statement.org/fileadmin/
Strobe/uploads/checklists/STROBE_checklist_v4_combined.pdf).
A-IV

Statistics: Describe the statistical methods used in enough detail to
enable a knowledgeable reader with access to the original data to verify
the reported results. Statistically important data should be given in the
text, tables and figures. Provide details about randomization, describe
treatment complications, provide the number of observations, and
specify all computer programs used.
Results: Present your results in logical sequence in the text, tables, and
figures. Do not present all the data provided in the tables and/or figures in
the text; emphasize and/or summarize only important findings, results,
and observations in the text. For clinical studies provide the number
of samples, cases, and controls included in the study. Discrepancies
between the planned number and obtained number of participants
should be explained. Comparisons, and statistically important values
(i.e. P value and confidence interval) should be provided.
Discussion: This section should include a discussion of the data.
New and important findings/results, and the conclusions they lead
to should be emphasized. Link the conclusions with the goals of
the study, but avoid unqualified statements and conclusions not
completely supported by the data. Do not repeat the findings/results
in detail; important findings/results should be compared with those
of similar studies in the literature, along with a summarization. In
other words, similarities or differences in the obtained findings/results
with those previously reported should be discussed. Limitations
of the study should be detailed. In addition, an evaluation of the
implications of the obtained findings/results for future research
should be outlined.
References
Cite references in the text, tables, and figures with numbers in
parentheses. Number references consecutively according to the
order in which they first appear in the text. Journal titles should be
abbreviated according to the style used in Index Medicus (consult List
of Journals Indexed in Index Medicus). Include among the references
any paper accepted, but not yet published, designating the journal
and followed by, in press.
Examples of References:
1. List all authors.
Deeg HJ, O’Donnel M, Tolar J. Optimization of conditioning for
marrow transplantation from unrelated donors for patients with
aplastic anemia after failure immunosuppressive therapy. Blood
2006;108:1485-1491.
2.Organization as author
Royal Marsden Hospital Bone Marrow Transplantation Team. Failure
of syngeneic bone marrow graft without preconditioning in posthepatitis
marrow aplasia. Lancet 1977;2:742-744.
3.Book
Wintrobe MM. Clinical Hematology, 5th ed. Philadelphia, Lea &
Febiger, 1961.
4. Book Chapter
Perutz MF. Molecular anatomy and physiology of hemoglobin. In:
Steinberg MH, Forget BG, Higs DR, Nagel RI, (eds). Disorders of
Hemoglobin: Genetics, Pathophysiology, Clinical Management. New
York, Cambridge University Press, 2000.
5.Abstract
Drachman JG, Griffin JH, Kaushansky K. The c-Mpl ligand
(thrombopoietin) stimulates tyrosine phosphorylation. Blood
1994;84:390a (abstract).
6.Letter to the Editor
Rao PN, Hayworth HR, Carroll AJ, Bowden DW, Pettenati MJ. Further
definition of 20q deletion in myeloid leukemia using fluorescence in
situ hybridization. Blood 1994;84:2821-2823.
7. Supplement
Alter BP. Fanconi’s anemia, transplantation, and cancer. Pediatr
Transplant. 2005;9(Suppl 7):81-86
Brief Reports
Abstract length: Not to exceed 150 words.
Article length: Not to exceed 1200 words.
Introduction: State the purpose and summarize the rationale for the
study.
Materials and Methods: Clearly describe the selection of the
observational or experimental participants. Identify the methods
and procedures in sufficient detail. Provide references to established
methods (including statistical methods), provide references to brief
modified methods, and provide the rationale for their use and an
evaluation of their limitations. Identify all drugs and chemicals used,
including generic names, doses, and routes of administration.
Statistics: Describe the statistical methods used in enough detail to
enable a knowledgeable reader with access to the original data to verify
the reported findings/results. Provide details about randomization,
describe treatment complications, provide the number of observations,
and specify all computer programs used.
Results: Present the findings/results in a logical sequence in the text,
tables, and figures. Do not repeat all the findings/results in the tables
and figures in the text; emphasize and/or summarize only those that
are most important.
Discussion: Highlight the new and important findings/results of the
study and the conclusions they lead to. Link the conclusions with the
goals of the study, but avoid unqualified statements and conclusions
not completely supported by your data.
Case Reports
Abstract length: Not to exceed 100 words.
Article length: Not to exceed 1200 words.
Case Reports can include maximum 1 figure and 1 table or 2 figures
or 2 tables.
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Case reports should be structured as follows:
Abstract
An unstructured abstract that summarizes the case.
Introduction: A brief introduction (recommended length: 1-2
paragraphs).
Case Presentation: This section describes the case in detail, including
the initial diagnosis and outcome.
Discussion:This section should include a brief review of the relevant
literature and how the presented case furthers our understanding to
the disease process.
Invited Review Articles
Abstract length: Not to exceed 300 words.
Article length: Not to exceed 4000 words.
Review articles should not include more than 100 references.
Reviews should include a conclusion, in which a new hypothesis or
study about the subject may be posited. Do not publish methods for
literature search or level of evidence. Authors who will prepare review
articles should already have published research articles on therel
evant subject. The study’s new and important findings should be
highlighted and interpreted in the Conclusion section. There should
be a maximum of two authors for review articles.
Images in Hematology
Article length: Not exceed 200 words.
Authors can submit for consideration an illustration and photos that
is interesting, instructive, and visually attractive, along with a few
lines of explanatory text and references. Images in Hematology can
include no more than 200 words of text, 5 references, and 3 figure or
table. No abstract, discussion or conclusion are required but please
include a brief title.
Letters to the Editor
Article length: Not to exceed 500 words.
Letters can include no more than 500 words of text, 5-10 references, and
1 figure or table. No abstract is required, but please include a brief title.
Tables
Supply each table on a separate file. Number tables according to the
order in which they appear in the text, and supply a brief caption
for each. Give each column a short or abbreviated heading. Write
explanatory statistical measures of variation, such as standard deviation
or standard error of mean. Be sure that each table is cited in the text.
Figures
Figures should be professionally drawn and/or photographed.
Authors should number figures according to the order in which they
appear in the text. Figures include graphs, charts, photographs, and
illustrations. Each figure should be accompanied by a legend that
does not exceed 50 words. Use abbreviations only if they have been
introduced in the text. Authors are also required to provide the level
of magnification for histological slides. Explain the internal scale and
identify the staining method used. Figures should be submitted as
separate files, not in the text file. High-resolution image files are not
preferred for initial submission as the file sizes may be too large. The
total file size of the PDF for peer review should not exceed 5 MB.
Authorship
Each author should have participated sufficiently in the work to assume
public responsibility for the content. Any portion of a manuscript that is
critical to its main conclusions must be the responsibility of at least 1 author.
Contributor’s Statement
All submissions should contain a contributor’s statement page. Each
manuscript should contain substantial contributions to idea and
design, acquisition of data, or analysis and interpretation of findings.
All persons designated as an author should qualify for authorship,
and all those that qualify should be listed. Each author should
have participated sufficiently in the work to take responsibility for
appropriate portions of the text.
Acknowledgments
Acknowledge support received from individuals, organizations,
grants, corporations, and any other source. For work involving a
biomedical product or potential product partially or wholly supported
by corporate funding, a note stating, “This study was financially
supported (in part) with funds provided by (company name) to
(authors’ initials)”, must be included. Grant support, if received,
needs to be stated and the specific granting institutions’ names and
grant numbers provided when applicable.
Authors are expected to disclose on the title page any commercial or
other associations that might pose a conflict of interest in connection
with the submitted manuscript. All funding sources that supported
the work and the institutional and/or corporate affiliations of the
authors should be acknowledged on the title page.
Ethics
When reporting experiments conducted with humans indicate that
the procedures were in accordance with ethical standards set forth
by the committee that oversees human experimentation. Approval of
research protocols by the relevant ethics committee, in accordance
with international agreements (Helsinki Declaration of 1975, revised
2002 available at http://www.wma.net/e/policy/b3.htm, “Guide for
the Care and use of Laboratory Animals” www.nap.edu/catalog/5140.
html/), is required for all experimental, clinical, and drug studies.
Patient names, initials, and hospital identification numbers should
not be used. Manuscripts reporting the results of experimental
investigations conducted with humans must state that the study
protocol received institutional review board approval and that the
participants provided informed consent.
Non-compliance with scientific accuracy is not in accord with scientific
ethics. Plagiarism: To re-publish-whole or in part-the contents
of another author’s publication as one’s own without providing a
reference. Fabrication: To publish data and findings/results that
do not exist. Duplication: Use of data from another publication,
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which includes re-publishing a manuscript in different languages.
Salamisation: To create more than one publication by dividing the
results of a study preternaturally.
We disapprove of such unethical practices as plagiarism, fabrication,
duplication, and salamisation, as well as efforts to influence the review
process with such practices as gifting authorship, inappropriate
acknowledgements, and references. Additionally, authors must
respect participant right to privacy.
On the other hand, short abstracts published in congress books that
do not exceed 400 words and present data of preliminary research,
and those that are presented in an electronic environment are not
accepted pre-published work. Authors in such situation must declare
this status on the first page of the manuscript and in the cover letter.
(The COPE flowchart is available at: http://publicationethics.org)
We use iThenticate to screen all submissions for plagiarism before
publication.
Turkish Journal of Hematology uses plagiarism screening service
to verify the originality of content submitted before publication.
Conditions of Publication
All authors are required to affirm the following statements before their
manuscript is considered: 1. The manuscript is being submitted only
to The Turkish Journal of Hematology; 2. The manuscript will not be
submitted elsewhere while under consideration by The Turkish Journal
of Hematology; 3. The manuscript has not been published elsewhere,
and should it be published in The Turkish Journal of Hematology it
will not be published elsewhere without the permission of the editors
(these restrictions do not apply to abstracts or to press reports for
presentations at scientific meetings); 4. All authors are responsible for
the manuscript’s content; 5. All authors participated in the study concept
and design, analysis and interpretation of the data, drafting or revising
of the manuscript, and have approved the manuscript as submitted. In
addition, all authors are required to disclose any professional affiliation,
financial agreement, or other involvement with any company whose
product figures prominently in the submitted manuscript.
Authors of accepted manuscripts will receive electronic page proofs and
are responsible for proofreading and checking the entire article within
two days. Failure to return the proof in two days will delay publication.
If the authors cannot be reached by email or telephone within two weeks,
the manuscript will be rejected and will not be published in the journal.
Copyright
At the time of submission all authors will receive instructions for
submitting an online copyright form. No manuscript will be considered
for review until all authors have completed their copyright form. Please
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A-VII

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A-VIII

CONTENTS
Review Article
342 Diagnosis of Invasive Fungal Diseases in Hematological Malignancies: A Critical Review of Evidence and
Turkish Expert Opinion (TEO-2)
Sevtap Arıkan Akdağlı, Alpay Azap, Figen Başaran Demirkazık, Beyza Ener, Sibel Aşcıoğlu Hayran, Özlem Özdemir Kumbasar,
Gökhan Metan, Zekaver Odabaşı, Ömrüm Uzun, Hamdi Akan
Research Articles
357 The Relationship between P-Selectin Polymorphisms and Thrombosis in Antiphospholipid Syndrome: A Pilot Case-Control Study
Nilüfer Alpay, Veysel Sabri Hançer, Burak Erer, Murat İnanç, Reyhan Diz-Küçükkaya
363 Serum Bcl-2 Levels in Patients with β-Thalassemia Minor: A Pilot Study
İrfan Yavaşoğlu, Gökhan Sargın, Gürhan Kadıköylü, Aslıhan Karul, Zahit Bolaman
367 Duffy and Kidd Genotyping Facilitates Pretransfusion Testing in Patients Undergoing Long-Term Transfusion Therapy
Diana Remeikiene, Rasa Ugenskiene, Arturas Inciura, Aiste Savukaityte, Danguole Raulinaityte, Erika Skrodeniene,
Renata Simoliuniene, Elona Juozaityte
374 Bone-Specific Alkaline Phosphatase Levels among Patients with Multiple Myeloma Receiving Various Therapy Options
Güven Çetin, Ahmet Emre Eşkazan, M. Cem Ar, Şeniz Öngören Aydın, Burhan Ferhanoğlu, Teoman Soysal, Zafer Başlar, Yıldız Aydın
381 The Relationship of T Helper-2 Pathway Components Interleukin-4, Interleukin-10, Immunoglobulin E, and Eosinophils with
Prognostic Markers in Non-Hodgkin Lymphoma: A Case-Control Study
Nil Güler, Engin Kelkitli, Hilmi Atay, Dilek Erdem, Hasan Alaçam, Yüksel Bek, Düzgün Özatlı, Mehmet Turgut, Levent Yıldız, İdris Yücel
388 The Association of HLA Class 1 and Class 2 Antigens with Multiple Myeloma in Iranian Patients
Arezou Sayad, Mohammad Taghi Akbari, Mahshid Mehdizadeh, Elham Roshandel, Soheila Abedinpour, Abbas Hajifathali
394 New Insights on Iron Study in Myelodysplasia
Noha M. El Husseiny, Dina Ahmed Mehaney, Mohamed Abd El Kader Morad
Case Reports
399 Severe Myelotoxicity Associated with Thiopurine S-methyltransferase*3A/*3C Polymorphisms in a Patient with Pediatric
Leukemia and the Effect of Steroid Therapy
Burcu Fatma Belen, Türkiz Gürsel, Nalan Akyürek, Meryem Albayrak, Zühre Kaya, Ülker Koçak
403 Intravascular Large B-Cell Lymphoma Diagnosed on Prostate Biopsy: A Case Report
Nazan Özsan, Banu Sarsık, Asu Fergün Yılmaz, Adnan Şimşir, Ayhan Dönmez
408 Primary Splenic Angiosarcoma Revealed by Bone Marrow Metastasis
Soumaya Anoun, Sofia Marouane, Asmae Quessar, Said Benchekroun
411 Aplastic Anemia Associated with Oral Terbinafine: A Case Report and Review of the Literature
Bülent Kantarcıoğlu, Hüseyin Kemal Türköz, Güven Yılmaz, Funda Pepedil Tanrıkulu, Işık Kaygusuz Atagündüz,
Cafer Adıgüzel, Tülin Fıratlı Tuğlular
A-IX

Letters to the Editor
417 Significant Differences in Thymic Index of Thalassemia Major Patients
Yeşim Oymak, Bülent Güzel, Hüseyin Gümüş, Erdem Dağlıoğlu, Ali Ayçiçek, Ahmet Koç, Derya Özyürük
420 c.761C>T Mutation Linked Hyper IgM Syndrome Presenting with Hypertransaminasemia and Arthritis
Mehmet Halil Celiksoy, Stephan Borte, Aydan İkincioğulları, Meltem Ceyhan Bilgici, Filiz Karagöz, Ayhan Gazi Kalaycı,
Alişan Yıldıran
422 Blastic Plasmacytoid Dendritic Cell Neoplasm: Single-Center Experience with Two Cases in One Year
Alexandra Agapidou, Sophia Vakalopoulou, Dimitra Markala, Christina Chadjiaggelidou, Maria Tzimou,
Theodosia Papadopoulou, Vasileia Garypidou
424 Mogamulizumab Treatment in a Hemodialysis Patient with Adult T-Cell Leukemia/Lymphoma
Mari Yoshihara, Yasushi Kubota, Makoto Fukuda, Tomoya Kishi, Yuji Ikeda, Shinya Kimura
426 Chediak-Higashi Syndrome: A Case Report of a Girl without Silvery Hair and Oculocutaneous Albinism Presenting with
Hemophagocytic Lymphohistiocytosis
Murat Elevli, Halil Uğur Hatipoğlu, Mahmut Civilibal, Nilgün Selçuk Duru, Tiraje Celkan
428 Gaucher Cells or Pseudo-Gaucher Cells: That’s the Question
Deniz Gören Şahin, Hava Üsküdar Teke, Mustafa Karagülle, Neslihan Andıç, Eren Gündüz, Serap Işıksoy, Olga Meltem Akay
430 Quilty Effect after Extracorporeal Photopheresis in a Patient with Severe Refractory Cardiac Allograft Rejection
Özgür Ulaş Özcan, Tamer Sayın, Gürbey Soğut, Aylin Heper, Hüseyin Göksülük, Veysel Kutay Vurgun, Cansın Tulunay Kaya,
Elif Ezgi Üstün, Osman İlhan, Çetin Erol
432 A Pediatric Patient with Intravenous Cyclosporine Anaphylaxis Who Tolerated the Oral Form
Pamir Işık, Namik Özbek, Emine Dibek Mısırlıoğlu, Turan Bayhan, Suna Emir, Fatih Mehmet Azık, Bahattin Tunç
434 Acquired Hemophilia
Şinasi Özsoylu
Images in Hematology
435 Generalized Necrobiotic Xanthogranuloma in a Patient with Multiple Myeloma
Maria Jimenez Esteso, Jose Verdu, Francisco de Paz, Fabian Tarin
437 Aggressive Multiple Myeloma with Unusual Morphology
Mehmet Sönmez, Hasan Mücahit Özbaş, Nilay Ermantaş, Ümit Çobanoğlu
2014 Index
2014 Subject Index
2014 Author Index
A-X

NEWS
ISH 2014 World Congress
Report of the Chair of Council
The XXXVth World Congress of the International Society of
Hematology (ISH) was held on September 4-5, 2014, in Beijing,
China, hosted by the Chinese Society of Hematology (CSH). The
President of the Congress was Prof. Xiaojun Huang, the Co-Chairs
were Prof. Changgeng Ruan and Prof. Saijuan Chen, and Prof.
Kaiyan Liu served as the Secretary-General. The ISH 2014 Beijing
World Congress was highly successful and well organized, with a
balanced scientific program in basic and clinical hematology. The
venue was beautifully located next to the Beijing Olympic Garden
with the spectacular Bird’s Nest Stadium and Beijing National
Aquatics Center. There were 420 international members with
a total of 1450 attendees from 34 countries, and 410 abstracts
were submitted to the meeting. ISH Travel Awards sponsored
by the Congress Organizing Committee were presented to 22
junior hematologists from 20 countries. The scientific program
started with Prof. Zhu Chen’s excellent Miwa Lecture entitled
“Acute Promyelocytic Leukemia: Achievements, Challenges and
Expectations”. Zhu Chen (Shanghai Institute of Hematology)
described his original contributions in the role of ATRA and
its implications in APL. He reviewed the mechanisms of ATRA
in APL, the efficacy of arsenic trioxide (ATO), its synergy with
ATRA, and lessons learned from leukemic genomics. Chen also
focused on treatment algorithms in low-, intermediate-, and highrisk
APL patients. His talk was followed by Jacob M. Rowe (Shaare
Zedek Medical Center, Jerusalem, Israel), who reviewed the role
of stem cell transplantation, its indications, and survival data in
AML. Rowe addressed clear indications and eligibility of adult
AML patients for auto- and allogeneic HSCT. He also explained
current challenges as well as controversies in allo-HSCT and RIC
for older patients in CR1, the safety of MUD, the rate of relapse,
the ability to “cure” at relapse, and GVL effect. In the IAD-EAD-
APD joint session entitled “Genomic and Molecular Medicine in
Hematology”, Seichi Ogawa (Kyoto, Japan) covered novel somatic
mutations in AML and MDS. Ruben Mesa (Mayo Clinic, Scottsdale,
Arizona, USA) clearly highlighted molecular targeting in myeloid
malignancies and state-of-the art knowledge in myeloproliferative
neoplasms. Mesa elegantly covered targeting issues from TKIs,
i.e. imatinib, to novel therapeutics and their future implications.
Tayfun Özçelik (Bilkent University, Ankara, Turkey) demonstrated
very convincing data for careful interpretation of gene mutations in
hematologic malignancies. Özçelik also cautioned us on “reading”
and “translation” of genome sequencing data, giving excellent case
examples from his original research. He explained his pioneering
research in genomic sequencing and DNA-based diagnostics,
including forensics in Turkey, as well as his recent discovery of
the VLDR mutation in cerebellar hypoplasia associated with
“quadrupedal gait in humans”. During the congress there were also
sessions on case-based presentations. The meeting also included
various presentations on acute leukemias, lymphomas, CLL, CML,
multiple myeloma, and coagulation and platelet disorders. The oral
and poster sessions were well attended. During the ISH business
meetings, David Gómez-Almaguer (Mexico) was elected as the
new Secretary-General of the Inter-American Division (IAD),
replacing Carlos Ponzinibbio (Argentina), who had completed his
term. Sabri Kemahlı was reelected as the Secretary-General of the
European-African Division (EAD).
Future Perspectives
The ISH is the only world hematology organization, established
by the national hematology societies in 1946. The ISH has always
had the strongest commitment to serve, educate, and provide
up-to-date knowledge, as well as to collaborate with professional
societies including the ASH, ICSH, ISTH, and ISEH. As the newly
elected Chair of Council, I envision a future for the Society as
a strong source of global education in hematology, embracing all
countries. I am planning to serve the Society within the framework
of the following major topics: (a) to have an interactive, regularly
updated, and user-friendly website; (b) to establish scientific
working groups dealing with specified issues; (c) to establish a
‘Code of Conduct’ for scientific ethics; (d) to make the biannual
congresses a venue where all basic and clinical researchers are able
to present their latest findings, and where hematologists in general
practice can be informed and inspired by the very best courses
and lecturers; (e) to establish training courses and educational
meetings between the biannual congresses in joint activity with
national hematology meetings, aimed at enhancing the training
and professional development of junior members and particularly
those in Africa, Asia, Eastern Europe, and Latin America; (f) to
improve our fiscal responsibilities and our financial status; and
(g) to improve communication among ISH members through an
efficient website and to stimulate interactive bridging with other
related professional hematological societies.
We look forward to seeing you all at the ISH 2016
World Congress, in Glasgow-UK, on April 18-21, 2016
(http://www.ish2016.com).
Emin Kansu, M.D., FACP
ISH Chair of Council
eminkansu47@gmail.com
A-XI

Review Article
DOI: 10.4274/tjh.2014.0218
Diagnosis of Invasive Fungal Diseases in Hematological
Malignancies: A Critical Review of Evidence and Turkish
Expert Opinion (TEO-2)
Hematolojik Malignitelerde Görülen İnvazif Fungal
İnfeksiyonların Tanısında Tanı Araçları: Kanıtlara
Eleştirel Bakış ve Türk Uzman Görüşleri (TUG-2)
Sevtap Arıkan Akdağlı1, Alpay Azap2, Figen Başaran Demirkazık3, Beyza Ener4, Sibel Aşcıoğlu Hayran5,
Özlem Özdemir Kumbasar6, Gökhan Metan7, Zekaver Odabaşı8, Ömrüm Uzun5, Hamdi Akan9
1Hacettepe University Faculty of Medicine, Department of Medical Microbiology, Ankara, Turkey
2Ankara University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Ankara, Turkey
3Hacettepe University Faculty of Medicine, Department of Radiology, Ankara, Turkey
4Uludağ University Faculty of Medicine, Department of Microbiology, Bursa, Turkey
5Hacettepe University Faculty of Medicine, Department of Infectious Diseases, Ankara, Turkey
6Ankara University Faculty of Medicine, Department of Pulmonary Diseases, Ankara, Turkey
7Erciyes University Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Kayseri, Turkey
8Marmara University Faculty of Medicine, Department of Infectious Diseases, İstanbul, Turkey
9Ankara University Faculty of Medicine, Department of Hematology, Ankara, Turkey
Abstract:
One of the most problematic issues in hematological malignancies is the diagnosis of invasive fungal diseases. Especially, the
difficulty of mycological diagnosis and the necessity of immediate intervention in molds have led to the adoption of “surrogate
markers” that do not verify but rather strongly suggest fungal infection. The markers commonly used are galactomannan (GM),
beta-glucan, and imaging methods. Although there are numerous studies on these diagnostic approaches, none of these markers
serve as a support for the clinician, as is the case in human immunodeficiency virus (HIV) or cytomegalovirus (CMV) infections.
This paper has been prepared to explain the diagnostic tests. As molecular tests have not been standardized and are not used
routinely in the clinics, they will not be mentioned here.
Key Words: Diagnosis, Invasive fungal infection, Imaging, Serology
Özet:
Hematolojik malignitelerin tedavisinde önemli sorunlardan birisi de invazif fungal infeksiyonların tanısıdır. Mikolojik tanıdaki
zorluklar ve hızlı müdahele etme gerekliliği, küf mantarlarının tanısında dolaylı işaretleyicilerin geliştirilmesine yol açmıştır.
En sık kullanılan tanı testleri galaktomannan, beta-glukan ve moleküler yöntemlerdir. Her ne kadar bu tanı yöntemleri ile ilgili
Address for Correspondence: Hamdi AKAN, M.D.,
Ankara University Faculty of Medicine, Department of Hematology, Ankara, Turkey
Phone: +90 532 424 26 40 E-mail: hamdiakan@gmail.com
Received/Geliş tarihi : May 30, 2014
Accepted/Kabul tarihi : August 14, 2014
342

Arıkan Akdağlı S, et al: Diagnosis of IFI in Hematological Malignancies
Turk J Hematol 2014;31:342-356
çok sayıda araştırma yapılmakta ise de, hiçbiri HIV ya da CMV’de olduğu gibi doğrudan yarar sağlamamaktadır. Tanı ile ilgili
bu yazı klinisyene eldeki araçları kullanma konusunda yol göstermeyi amaçlamaktadır. Moleküler testlere henüz standardize
edilmediği ve klinik kullanıma girmediği için bu yazıda değinilmeyecektir.
Anahtar Sözcükler: Tanı, İnvazif fungal infeksiyon, Görüntüleme, Seroloji
Introduction
One of the most problematic issues in hematological
malignancies is the diagnosis of invasive fungal diseases. In
particular, the difficulty of mycological diagnosis and the
necessity of immediate intervention in cases of molds have
led to the adoption of “surrogate markers” that do not verify
but rather strongly suggest fungal infection. The markers
commonly used are galactomannan (GM), beta-glucan, and
imaging methods. Although there are numerous studies on
these diagnostic approaches, none of these markers serve as
support for the clinician, as in human immunodeficiency
virus (HIV) or cytomegalovirus (CMV) infections. This
paper has been prepared to explain the diagnostic tests. As
molecular tests have not been standardized and are not used
routinely in clinics, they will not be mentioned here.
Conventional Microbiological Diagnostic Methods
Clinical manifestations of invasive fungal infections
(IFIs) generally are not agent-specific. Therefore,
radiological, histopathological, and microbiological features
are important in diagnosis. Although the radiological and
histopathological findings are very important and provide
possible evidence, the causative agent should be grown in
culture and preferably be identified to the species level for
definitive diagnosis. Accordingly, conventional (classical)
microbiological diagnostic methods remain the gold
standard in the diagnosis of IFIs [1,2,3,4].
Conventional Microbiological Diagnostic Methods and
Current Guidelines
Direct microscopic examination and culture of the
clinical samples constitute the conventional microbiological
diagnostic methods.
Direct Microscopic Examination
Direct microscopic examination of the sample is a rapid
and practical method that provides a chance for a possible
pre-diagnosis. The results of direct microscopy also allow
the interpretation of culture contamination in specimens
from which a mold is isolated later. The major factors
affecting the sensitivity of direct microscopic examination
include the collection of a sufficient volume of a suitable
clinical sample, application of staining methods within the
frame of related principles, and performance of microscopic
examination by experienced people on a sample involving
the whole specimen. The sensitivity of direct microscopy
widely varies depending on these factors. In order to
evaluate the microscopic structures of fungi, different stains
and wet coating methods can be used. Furthermore, very
important evidence for the diagnosis of fungal infections can
be acquired by histopathological evaluation of the biopsy
samples. The staining methods used in microbiological
and histopathological evaluation for the diagnosis of
opportunistic mycoses and the goals of use are summarized
in Table 1 [5,6].
Culture
The isolation of fungi in culture is a conventional
method, which remains the gold standard in providing
the definitive diagnosis of IFIs. The collection of sufficient
amounts of appropriate sample, rapid transport of the
specimen to the laboratory, the informing of the laboratory
of the tentative clinical diagnosis, and performance of the
laboratory examinations without delay according to standard
recommendations are among the main factors affecting the
success of a culture [5,6,7]. The culture method carries some
disadvantages along with important advantages; therefore,
the use of additional serological diagnostic methods,
particularly those aimed at early diagnosis, is recommended
along with culture. The advantages and disadvantages related
to the culture method [4,8,9] are presented in Table 2.
Available Guidelines Related to the Microbiological
Diagnosis of Invasive Fungal Infections
In previous years, guidelines for or involving sections on
fungal infection diagnosis have been published. The names
and major content of these guidelines are summarized in
Table 3.
Recommendations for Direct Microscopic Examination
and Culture Applications
Direct microscopic examination and culture are the main
indispensable methods for IFI diagnosis. Direct microscopic
examination, due to its advantages such as being rapid
and providing a possible pre-diagnosis, should necessarily
be performed. The culture method, with advantages such
as identification of the causative agent at species level and
accordingly prediction of antifungal susceptibility profile at
the species level further allowing performance of antifungal
susceptibility tests for that strain, is the gold standard that
should be performed as the fundamental diagnostic method
whenever possible. The use of culture in diagnosis has also
received the highest recommendation level as the main
diagnostic method in the current guidelines.
Diagnosis of Fungemia: Isolation of Fungi in Blood
Cultures
Principles of collecting samples for the isolation of fungi
in blood culture are the same as the standard principles of
blood culture [3]. Blood culture is an important method
for the isolation of Candida, Fusarium, Scedosporium,
343

Turk J Hematol 2014;31:342-356
Arıkan Akdağlı S, et al: Diagnosis of IFI in Hematological Malignancies
thermally dimorphic fungi causing endemic mycosis, and
the other yeasts with clinical importance [Blastoschizomyces
(Saprochaete), Rhodotorula, Trichosporon, etc.] and for the
diagnosis of infections caused by these fungi. If the fact that
Turkey is not in an endemic region for thermally dimorphic
fungi is considered, excluding possible travel-related
infections, isolation of fungi causing endemic mycosis from
blood does not carry primary importance. Fungi other
than those causing endemic mycoses and expected to be
isolated in blood culture can be isolated in blood culture
at varying rates in our country, with Candida spp. being the
leading isolate. However, the sensitivity of blood culture in
candidemia diagnosis is generally below the desired level.
Autopsy studies show that candidemia can be diagnosed by
blood culture in 50-70% of cases [10,11].
Different methods or parameters are being tested
to enhance the sensitivity of blood culture in fungemia
diagnosis, and the leading methods are lysis centrifugation
method and use of fungal media. The lysis centrifugation
method is especially recommended for the identification
of dimorphic fungi in blood culture [12]. However,
studies published in previous years, particularly those
Table 1. Direct microscopic examination methods used in the diagnosis of opportunistic mycoses [5,6].
Method Aim of Use Frequently Observed Structures
Wet-mount potassium hydroxide
(KOH) preparation
Wet-mount method using India ink
Gram staining
Fluorescent staining with calcofluor-white
Immunofluorescence staining/Giemsa
Gomori’s methenamine silver
(GMS) staining
By dissolution of organic matter in
the sample, allows detection of a
possible fungus in the sample more
easily
Visualization of the capsule
Especially in detecting yeasts
Performed to increase the probability
of detecting microscopic fungal
structures
Detection of Pneumocystis jirovecii
Histopathological examination of
tissue samples regarding all fungal
structures
Hyphae, arthroconidia
Capsule is seen as a “halo” that surrounds
the yeast cell
Gram-positive, budding yeast cells
(+pseudohyphae, -real hyphae)
Hyphae, arthroconidia
Cyst/trophozoite
Hyphae/yeast cells
Table 2. The advantages and disadvantages of culture method in the diagnosis of invasive fungal infections [4,8,9].
Advantages
It is a “gold standard” method allowing definitive
diagnosis.
Provides a chance for identification to the genus
and species level.
Helps to estimate the antifungal susceptibility profile
(in accordance with the knowledge on primary
resistance).
Allows performance of antifungal susceptibility
testing for the causative strain and hence determination
of the differences in the susceptibility profile at
strain level.
Disadvantages
Sensitivity and specificity are variable and may be affected by several
factors. Sensitivity rates are usually below the desired levels.
Collection of a sufficient volume from the appropriate sample is
among the most important factors affecting sensitivity.
In the assessment of growth, cutoff of colony-forming units that
can be used in the differentiation of contamination-colonization-infection
is not available.
False positive results due to contamination risk are possible (especially
for molds).
As the growth period is long (especially when molds are the causative
agents), its benefit in early diagnosis is limited.
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involving open systems, reported data indicating that the
use of the lysis centrifugation method might increase the
risk of contamination [4,13]. Beyond that, as the lysis
centrifugation method has been reported to be mainly
useful in the diagnosis of dimorphic fungi, it does not carry
primary importance in Turkey. On the other hand, use of
fungal media has been observed to be important not only
for the isolation of fungi causing endemic mycosis, but also
for the growth duration of yeasts (especially for Candida
glabrata); use of fungal media has been reported to shorten
the isolation period [14,15]. This finding is important, as
C. glabrata is isolated in varying rates in blood culture at
different centers in our country.
When aerobic culture bottles of different automated
systems are used for the isolation of fungi, the isolation rate
of C. glabrata has been demonstrated to differ according to
the automated system used, and the use of fungal media is
particularly recommended with systems yielding low rates
of isolation [16]. Other than that, study data are available
showing that the use of fungal media can be beneficial in
intensive care or hematology cases, where yeast growth
in blood may be found together with resistant or multiple
bacterial growth [14]. In light of these data, although current
guidelines primarily stipulate the use of automated, validated
blood culture systems, they emphasize that the sensitivity of
the system may change depending on the species studied and
the system itself [3]. The knowledge that the use of blood
culture bottles containing fungal media may shorten the
growth period and the recommendation that the decision
related to the use of these media should be made by the
related center also appear in the guidelines [12]. Additionally,
the Infectious Diseases Society of America (IDSA) and the
American Society for Microbiology (ASM) guidelines offer
the use of 2 aerobic blood culture bottles instead of a single
Table 3. The names and contents of new guidelines presenting recommendations related to the microbiological diagnosis
of invasive fungal infections.
Guideline
Content
Reference
No.
CLSI M54-A
Guidelines for implementing methods directed at
identification of fungi by direct microscopic examination and
culture in clinical samples
[12]
ECIL-3 - Guidelines for Classical
Diagnostic Procedures
ECIL - Guidelines for the Use of
Biological Markers
ECIL-3 - Guidelines for Mucormycosis
ESCMID – Guidelines for the Diagnosis
of Candida Diseases
IDSA-ASM Guidelines
ESCMID-ECMM Guidelines for
Phaeohyphomycosis
ESCMID-ECMM Guidelines for
Hyalohyphomycosis
ESCMID-ECMM Guidelines for
Mucormycosis
ESCMID-ECMM Guidelines for Rare
Invasive Yeast Infections
Classical diagnostic methods used for the diagnosis of IFIs in
leukemia cases
Recommendations related to the use of biological markers
for the diagnosis of IFIs in leukemia cases and hematopoietic
stem cell donors
Recommendations for the diagnosis and treatment of
mucormycosis in cases of hematological malignancies
Recommendations related to the use of conventional and
other diagnostic methods in different clinical presentations of
Candida
Recommendations for the use of a microbiology
laboratory in the diagnosis of infectious diseases (presents
recommendations on fungal infection agents along with other
microorganism groups)
Recommendations related to the diagnosis and treatment of
systemic phaeohyphomycosis caused by dematiaceous fungi
Recommendations for the diagnosis and treatment of
fusariosis, scedosporiosis, and other hyalohyphomycoses
Recommendations related to the diagnosis and treatment of
mucormycosis
Recommendations for the diagnosis and treatment of rare
invasive yeast infections
CLSI: Clinical and Laboratory Standards Institute, ECIL-3: European Conference on Infections in Leukaemia-3, ESCMID: European Society of Clinical Microbiology
and Infectious Diseases, IDSA: Infectious Diseases Society of America, ASM: American Society for Microbiology, ECMM: European Confederation of Medical Mycology.
[4]
[22]
[23]
[3]
[17]
[24]
[25]
[26]
[27]
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bottle for inoculation as an alternative to inoculation into
fungal media, if yeast fungemia is suspected [17].
Recommendation for the Isolation of Fungi from Blood
Culture
If the conditions of our country are taken into account,
fungi likely to be isolated from blood include Candida spp.,
the other yeasts, and Fusarium spp. In accordance with
the recommendations of the guidelines and the studies
performed using Candida spp., it is recommended that the
decision of using fungal media for inoculation should be
made considering the properties of the automated system
and the patient population of that center.
Routine Antifungal Susceptibility Testing and
Recommendations
Antifungal susceptibility testing should be performed
with certain indications to direct antifungal treatment, not for
all fungal strains isolated in routine practice. The indications
of antifungal susceptibility testing have gained accuracy
mostly for Candida strains, and comprehensive studies on
other fungi, especially Aspergillus, are also being carried out.
The indications for antifungal susceptibility testing include
strains isolated from normally sterile sites, unresponsiveness
to antifungal treatment, history of previous antifungal
treatment use, and decreased susceptibility to antifungal
drug(s) or isolates belonging to a resistant strain. Antifungal
susceptibility testing should be performed and interpreted
using reference methods for antifungal susceptibility tests
from the Clinical and Laboratory Standards Institute (CLSI)
or the European Committee on Antibiotic Susceptibility
Testing (EUCAST) by staff and centers experienced in
antifungal susceptibility testing and educated in mycology
[3,4,18,19,20,21].
Serological Tests
Serological tests, developed to aid in early diagnosis
and recommended to be used along with conventional
methods, are another test group that carries importance
in the microbiological diagnosis of IFIs. Currently, the
important serological tests used in routine practice are the
GM antigen test, beta-glucan test, cryptococcal antigen test,
and combined mannan-anti-mannan testing.
Galactomannan Test
GM is a molecule composed of mannan and
galactofuranose polymers found in the cell wall of Aspergillus
spp. and some other molds (Penicillium and Fusarium spp.)
[28,29]. It may be released into the environment during active
growth of the fungus. It has been shown in several studies
that determination of GM in serum, bronchoalveolar lavage
(BAL) fluid, and other samples by a commercial kit using
the sandwich enzyme immunoassay (EIA) method (Bio-Rad
Laboratories, Marne-La-Coquette, France) is beneficial in
the diagnosis of invasive aspergillosis (IA) [30,31,32,33].
The results are read by a spectrophotometer and expressed
as optical density index. It is strongly (AII) recommended
by the ECIL that it be performed as a screening test in bone
marrow transplants and in patients with hematological
malignancies in whom the incidence of IA is high (5-15%).
Again, strong evidence (AII level) supports screening to
be performed at 2- to 3-day intervals at least twice a week,
and an optical density index of >0.7 in a single sample and
an optical density index of >0.5 in 2 consecutive samples
Table 4. Factors affecting the performance of galactomannan testing.
Factor Affecting
Galactomannan Performance
Patient population
Site of infection
Sampling strategy
Interpretation
Sensitivity is high in bone marrow transplants with neutropenia and in patients
with hematological malignancies
Sensitivity is low in local infections
Sensitivity is high in frequent testing
IA incidence Sensitivity is higher in cases of GM >7%
The causative Aspergillus spp.
Sensitivity is low in A. fumigatus infections
Molecular configuration of GM Sensitivity is low if the specific epitope in the side chain of GM is

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Turk J Hematol 2014;31:342-356
suggests IA [22]. It is important to continue screening in
patients diagnosed with IA by GM testing (BII) and it was
demonstrated in studies that not observing a decrease in
optical density may be related to poor prognosis [34].
Additionally, revised European Organization for Research
and Treatment of Cancer/Mycoses Study Group (EORTC/
MSG) criteria emphasize that probable IA diagnosis can be
made by GM positivity even if conventional microbiological
evidence is not available [35].
There are several factors affecting the performance of
the GM test. These factors are summarized in Table 4. It
is emphasized that there may be false negative results in
non-neutropenic patients receiving antifungal prophylaxis/
treatment and in local infections, and false positive results
in patients with Fusarium infections and in those receiving
semi-synthetic β-lactam antibiotics [28,36,37,38,39,40].
However, recent studies showed a very low rate of false
positive GM related to piperacillin/tazobactam, which was
considered as the most common antibiotic associated with
false GM results [41,42,43]. Such kind of false positive
results can be avoided by obtaining the serum sample just
before the next dose of semi-synthetic β-lactam antibiotics
[44].
Other than serum, GM testing can be performed in BAL
fluid. It was reported in all meta-analyses that the sensitivity
of BAL GM is higher and the specificity is lower than that
of serum GM testing [45,46,47]. It is recommended to
perform GM analysis in bronchoscopic samples of patients
at high risk of IA as its negative predictive value is high.
It was pointed out that a BAL GM optical index of 3
supports definitive diagnosis [48,49]. The values between
these 2 limits are debatable. However, it is recommended
in meta-analyses that the cutoff index value be taken as 1.5
in patients with hematological malignancies and 1 in mixed
patient populations [45,46]. A study comparing culture and
GM in BAL fluid samples emphasized that growth might
be expected when the optical index is >1, and a correlation
with clinical studies was also demonstrated [50].
There are also various factors affecting the performance
of BAL GM testing. While the use of antifungal drugs active
in molds leads to an apparent decrease in sensitivity, no
significant difference could be found related to Aspergillus
spp. Furthermore, there is no difference in the sensitivity of
BAL GM in patients with or without neutropenia [45,50].
Similar to serum GM testing, the use of semi-synthetic
β-lactam antibiotics may lead to false positive results [45].
The standardization of bronchoscopy and bronchoscopic
material is the most urgent problem that should be solved
regarding BAL GM testing.
Conclusively, GM is a biomarker that can be used along
with clinical, radiological, and conventional microbiological
tests in IA diagnosis. In centers where high-risk patients
(bone marrow transplants and patients with hematological
malignancies) are followed, if a result can be achieved in
24 h and if computed tomography (CT) is available, it is
recommended to be used as a screening test. In Turkey, GM
testing twice a week for hospitalized patients is covered by
reimbursement. Multidisciplinary follow-up is needed in
high-risk patients and performance of bronchoscopy and
BAL GM analysis after CT is important to exclude or support
the diagnosis. There is a decrease in the sensitivity of GM
testing, and especially serum GM, in patients receiving
prophylaxis. It can be used as a diagnostic test when clinical
findings develop in this kind of patient or at centers where
scanning cannot be performed. However, it should not be
forgotten that this is a supplementary test that should always
be used together with other data.
1,3-beta-D-Glucan Test
The 1,3-beta-D-glucan (BG) test is one of the promising
non-culture-based early diagnostic tests for the diagnosis of
IFIs. BG is a cell wall component of many fungi, especially
Candida and Aspergillus spp. [51,52]. This test is based
on the reaction of BG with factor G of the horseshoe crab
coagulation cascade. In a preliminary study of 30 candidemic
patients and 30 healthy controls, a serum BG level of 60 pg/
mL was chosen as the cutoff. After determining this cutoff
value, the BG test was evaluated in 283 patients with acute
myeloid leukemia or myelodysplastic syndrome and the
sensitivity, specificity, and negative predictive value of the
test in proven and probable IFIs was 100%, 90%, and 100%,
respectively [51]. Later, a cutoff value of 80 pg/mL, which
is the currently accepted positive cutoff value for the test,
was found to have better specificity in a multicenter study
[53]. In an in vitro study, reactivity of 127 clinical fungal
isolates belonging to 40 different genera was evaluated with
the Glucatell assay [54]. Compared with the reactivity of
Aspergillus spp. with the BG test, Bipolaris spicifera, Sporothrix
schenckii, Wangiella dermatitidis, and Penicillium marneffei
isolates showed stronger reactivity and Paecilomyces spp.,
Scopulariopsis spp., Fusarium spp., Phialophora verrucosa,
and Exophiala jeanselmei showed some reactivity. Among the
tested clinical yeast isolates, Saccharomyces spp., Rhodotorula
rubra, and Trichosporon asahii were found to have similar
test reactivity when compared to Candida spp. In a clinical
study, sensitivity of the BG test for the diagnosis of Candida
parapsilosis was found to be lower compared to other
Candida spp. (78% vs. 90%, respectively) [53]. This test can
also be positive in Pneumocystis jirovecii infections and the
sensitivity of the test is very high: 96%, with a specificity of
84% [55]. The performance of the test in BAL fluid was also
evaluated; however, the sensitivity of detecting an IFI using
BAL specimens was not significantly increased over testing
of serum alone [56].
The BG test is usually not positive in the case of fungal
colonization, and detection of circulating BG levels may
be used as a surrogate marker not only for diagnosing IFIs
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but also for assessing the effectiveness of therapy [51,57].
Diagnostic levels and serum kinetics of the BG test were
found to be similar when compared to the GM antigen test
for the diagnosis of IA in neutropenic patients [57]. In the
same study, the combination of BG and GM antigen tests
improved the specificity and positive predictive value to
100%. In another clinical study performed in hematologic
malignancy patients with IA, the sensitivity of the BG test
and GM antigen test was 67% and 38%, respectively [39].
Interestingly, diagnostic accuracy of the GM antigen test
was 13% per serum sample in A. fumigatus-positive patients
compared to 49% positivity in patients with non-fumigatus
Aspergillus spp.; BG test positivity was similar between A.
fumigatus and non-fumigatus Aspergillus spp.
The overall pooled sensitivity and specificity of the
test for the diagnosis of IFIs is 77% and 85% [58]. Those
values seem promising, but there are no prospective
studies evaluating the use of the BG test in the diagnosis
and treatment of IFIs in hematology-oncology patients.
Two consecutive positive antigenemia assays have very
high specificity, positive predictive value, and negative
predictive value but the sensitivity is not satisfactory, so the
BG test needs to be combined with clinical, radiological,
and microbiological findings [59]. Ideal cutoff values and
timing of serum samples (like 2 or 3 times a week) should
be determined. Currently, use of the test at least twice a
week is moderately recommended in some guidelines for the
screening or diagnosis of invasive Aspergillus and Candida
infections [3,22]. Table 5 summarizes the differences
between the GM and BG tests.
Cryptococcal Antigen Tests
The polysaccharide capsule that surrounds Cryptococcus
neoformans is the target structure in serological tests, due
to its antigenic structure. LA and EIA are the methods
accepted in the serological diagnosis of cryptococcosis [22].
The concordance of LA and EIA kits developed by different
companies was found to be higher than 90% [62]. In a
systematic review performed after January 1998 evaluating
7 studies, 6 of which were retrospective, it was reported
that cerebrospinal fluid (CSF) antigen test sensitivity
in cryptococcal meningitis was 97% [63]. Although the
effect of CSF antigen titer on disease prognosis has not
been clearly defined, a CSF or serum antigen titer higher
than 1/512 was associated with disseminated infection and
unresponsiveness to treatment [64,65]. Antigen titer, tested
again at least 7 days after the first test, was reported to
decrease by 4-fold in patients with treatment response [66].
The sensitivity of the serum antigen test was reported to be
between 62% and 67% in pulmonary cryptococcosis and
cases of other organ involvement. Antigen test specificity in
both serum and CSF samples was determined to be 93-100%
[64,65,66,67]. Serum antigen positivity has been reported
in HIV-positive patients with disseminated disease. It should
Table 5. Basic characteristics of galactomannan and 1,3-beta-D-glucan tests including bronchoalveolar lavage [56,60,61].
Galactomannan
Diagnostic spectrum Aspergillus a Panfungal b
Method
Commercial kit
Cutoff (serum)
BAL
‘Sandwich’ ELISA
Latex agglutination
Bio-Rad (France)
Pastorex Aspergillus
0.5-1.5
1
1,3-beta-D-glucan
Calorimetric
Early diagnosis 5-8 days 3-10 days
Fungitell (USA)
Fungitec-G MK (Japan)
Wako (Japan)
Maruha (Japan)
Fungitell, 80 pg/mL
Others, 11-20 pg/mL
Serum, plasma
Sensitivity
Specificity
29%-100%
20%-100%
47%-98%
86%-98%
BAL (sensitivity, specificity) 56%-100%, 76%-100% 50%-93%, 55%-73%
Use in monitoring treatment + Ø
Cost + ++
a Be cautious in positivity to Penicillium, Histoplasma capsulatum, and Fusarium.
b Except Mucorales and Cryptococcus neoformans.
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be taken into account that serum antigen tests may give
false negative results in cancer patients [22]. False positive
test results at low titers were reported more frequently in
LA tests than in EIA. False negative results are more likely
with kits where clinical samples are not pre-treated with
pronase [68]. In a study performed between January 1989
and December 1999, 3828 CSF cryptococcal antigen tests
of cancer patients were evaluated, and positive results were
reported in 12 patients (0.3%). Six of these patients were
found to have other conditions involving the central nervous
system and it was recommended that test results of such
patients be interpreted carefully because of probable false
positive results [69]. Cryptococcal antigen testing in serum
and CSF samples of patients with cryptococcal meningitis
and disseminated cryptococcosis is recommended with
an AII evidence level, and the use of the test in following
treatment response is recommended with a CIII evidence
level by the ECIL [22].
Although cryptococcosis is not a common disease in
Turkey, cryptococcal meningitis should be included in the
differential diagnosis of central nervous system disorders
of stem cell transplants or patients treated with intense
chemotherapy regimens, and cryptococcal antigen testing
should be performed on the CSF samples of such patients.
Mannan/Anti-Mannan Tests
Determination of mannan antigen (Mn) and antimannan
antibody (A-Mn) by ELISA method has become
one of the most frequently used serological methods in the
diagnosis of invasive candidiasis [22]. A systematic review,
evaluating 14 studies (13 retrospective, 1 prospective)
including a total of 1220 patients (453 invasive candidiasis
cases, 767 controls), reported that when performed
separately the sensitivity of Mn and A-Mn tests was 58% and
59%, respectively, whereas the specificity was 93% for Mn
and 83% for A-Mn. However, if the positivity of one of these
tests (Mn/A-Mn combination) is considered to be sufficient
for diagnosis, sensitivity reaches 83% without a significant
decrease in specificity (86%) [70]. In 73% of 45 patients
with candidemia, at least one of the tests yielded positive
results 6-7 days before the culture results were available, and
in 21 patients who developed hepatosplenic candidiasis, a
positive result was achieved approximately 16 days before
the culture results [71,72]. Among Candida spp., the highest
sensitivity was achieved for Candida albicans [70]. Seven
of the studies evaluated in this review were performed in
cancer patients, while the other 7 studies were carried out in
intensive care units and surgery clinics. The heterogeneity
of the methods used in the studies is intriguing. When the
hematology-oncology patients were evaluated as a subgroup,
the sensitivity of the test was 71-100% and the specificity
ranged between 53% and 92% [70]. It was reported that
response to Mn was especially significant after resolution of
neutropenia [73]. A study that compared the Mn, A-Mn, and
BG test results in 56 candidemia patients, including 9 stem
cell transplants or patients with hematological malignancies
and 12 patients with solid tumors, reported the sensitivity
of the tests as 58.9%, 62.5%, and 87.5%, respectively, and
the specificity as 97.5%, 65%, and 85.5%, respectively. While
the diagnostic sensitivity of the Mn/A-Mn combination
increased to 89.3%, specificity remained at 63% [74]. ECIL
guidelines recommend the use of Mn and A-Mn together
with an evidence level of BII, and the use of Mn/A-Mn
combination in the diagnosis of hepatosplenic candidiasis
with an evidence level of BIII and in the diagnosis of
candidemia in hematology-oncology patients with evidence
level CII. In the same guidelines, the use of the BG test in
the diagnosis of invasive fungal disease is recommended at
the BII evidence level [22]. In the ESCMID guidelines for
the diagnosis of Candida infections, the use of Mn/A-Mn
combination is recommended with the same evidence level
as the use of BG.
Recommendation
Considering the economic burden of performing 2
separate tests for the Mn/A-Mn combination, the similar
clinical pictures in cancer patients with several other fungi
besides Candida, and the panfungal character of the BG test
contributing to the diagnosis of most of these conditions, the
use of the BG test seems to be more suitable in neutropenic
cancer patients in Turkey. Each center should decide which
test they will use according to the incidence of invasive
fungal disease, technical infrastructure, and target patient
groups.
Radiological Diagnosis of Invasive Fungal Infections
CT is a more sensitive imaging method than chest X-ray
in the diagnosis and differential diagnosis of pulmonary
infections in immunosuppressed patients. CT is particularly
indicated if chest X-ray is normal or near normal in patients
suspected of pulmonary infections [75,76]. Currently,
the entire lung can be scanned in a single breath-hold
with multislice spiral CT (MSCT) systems. Continuously
acquired slices of 5 mm in thickness can be used in routine
evaluation. However, in order to identify the halo sign seen
in fungal infections, thinner slices (1-2 mm) should be used
in evaluation. The resolution of thin slices obtained with
MSCT is sufficient to determine parenchymal lesions, and
the use of classical high-resolution CT (HRCT) technique
before MSCT is not necessary. MSCT especially provides
better imaging than HRCT in patients who cannot hold their
breath. However, while HRCT scans obtained in the prone
position are helpful in the diagnosis of patients suspected
of early fibrosis, HRCT scans obtained in expiration phase
aid in the diagnosis of patients suspected of bronchiolitis
obliterans [75].
There is no need to use intravenous contrast media
for MSCT for detection and differential diagnosis of
parenchymal infections in immunosuppressed patients.
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However, at the later stages, if there is suspicion of a rare
vascular complication such as mycotic pulmonary artery
aneurysm or aortic aneurysm, intravenous contrast media
should be used. Intravenous contrast media are used for liver
and spleen imaging of patients suspected of disseminated
candidiasis [75].
Symptoms of IFIs are not specific in immunosuppressed
patients and differential diagnosis from infections caused by
other microorganisms and noninfectious causes should be
made. Therefore, radiologists should be informed in detail
about the history and clinical-laboratory findings (primary
disease, history of chemotherapy or radiotherapy, fever,
respiratory distress, neutropenia, etc.) of the patients when
they are evaluating thoracic CT scans.
Thorax CT Findings in Invasive Fungal Infections
Chest X-ray findings in immunosuppressed neutropenic
patients are nonspecific and the assessment should be done
by CT. A nodule is detected in the thorax CT scans of 82%-
94% of patients with IFIs; the nodule is generally 1 cm or
more in diameter. Nodules are more frequent in IFIs than in
bacterial or viral infections. In particular, the “halo” sign at
the periphery of the nodule or the “air crescent” sign within
the nodule are findings in favor of IFIs [75,76,77].
The halo sign is a ground-glass opacity surrounding
a nodule or a mass in CT [78]. It was first described as
a sign of hemorrhage around the foci of IA (Figure 1).
Besides Aspergillus infections, it may be seen in Candida
infections and mucormycosis. The halo sign is nonspecific,
and it may be seen in other nodules with hemorrhage or
as an in situ adenocarcinoma at the periphery of invasive
adenocarcinoma. The halo sign is seen more frequently
in patients with hematological malignancies and stem cell
transplants than in solid organ transplants. While a halo sign
is found in the majority of patients with invasive Aspergillus
infection in the first days of infection (88-96%), its prevalence
decreases with the progression of disease and it is present in
18-19% of patients at the end of 2 weeks [79,80].
The reversed halo sign, seen in approximately 4% of
IFIs, is defined as a focal, rounded area of ground-glass
opacity surrounded by a complete or nearly complete ring of
consolidation. While it is seen in 19% of mucormycosis cases,
its prevalence is lower than 1% in Aspergillus infections.
Therefore, the reversed halo sign shows that mucormycosis
should be considered, and it aids in selecting the appropriate
antifungal agent in treatment [81].
At 2-3 weeks after commencement of treatment, along
with the resolution of neutropenia, cavitation develops within
the consolidation or within the nodule. Cavitation usually
shows that prognosis is good. An air crescent sign may be
present or absent. The air crescent sign is a crescent-like air
space within the cavity, separating a mass from the cavity
wall [78] (Figures 2 and 3). Characteristically, it shows that
Figure 1. Invasive Aspergillus infection showing a nodule
with a halo sign at the periphery (arrows).
Figure 2. Aspergillus infection showing a nodule with
cavitation and air crescent sign (arrow).
the infarcted lung is separated from the wall in IA. However,
it can be seen in conditions such as tuberculosis infection,
Wegener granulomatosis, lung cancer, and hemorrhage
within the cavity. Although the air crescent sign is a rare
finding in the early stages of invasive Aspergillus infections,
the prevalence increases with the progression of disease [75].
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Turk J Hematol 2014;31:342-356
Figure 3. Invasive aspergillosis infection showing nodular
densities, some with cavitation and air crescent signs.
Figure 4. Mucormycosis showing nodular densities, some
with cavitation.
Figure 5. Pneumocystis pneumonia showing bilateral,
perihilar ground-glass opacities; the lung periphery is
spared.
The nodule may grow within 10 days of commencing
antifungal treatment in IFIs. Some researchers explained this
by the gathering of immune cells along with the improvement
in bone marrow. Hence, even though the nodule enlarges in
the first 10 days of treatment, if the GM level is low and
the number of neutrophils is high, it is recommended not to
change the antifungal treatment [79,80].
Aspergillus bronchopneumonia develops in
approximately 10% of invasive Aspergillus infections. This
infection, also known as airway IA, is characterized by
the presence of Aspergillus organisms deep in the airway
basement membrane. Clinical manifestations include
bronchopneumonia, tracheobronchitis, and bronchiolitis.
There may be consolidation areas predominantly in the
peribronchiolar regions. Lobar consolidations may be rarely
seen. Generally, there are no radiological findings in acute
tracheobronchitis. In rare cases, there may be thickening
of tracheal or bronchial walls. “Tree-in-bud” signs, which
indicate endobronchiolar or peribronchiolar disease,
and centrilobular nodules may be seen in bronchiolitis.
Centrilobular nodules may also be detected in endobronchial
spread of tuberculosis, atypical tuberculosis infections, viral
pneumonias, and mycoplasma pneumonias. Therefore, when
bronchiolitis findings are detected in a CT scan, primarily
infections related to bacterial or viral microorganisms are
considered, as they are more frequent [76].
There is pulmonary involvement in 30% of cases of
mucormycosis. Radiological findings are not specific;
consolidation, nodule, mass, cavitation, or abscess
development may be seen (Figure 4) [76].
In Pneumocystis jiroveci pneumonia, although chest
X-rays are normal, perihilar ground-glass opacities showing
patchy or geographic distribution can be identified in
HRCT (Figure 5). Frequently, there is interlobular septal
thickening. Cystic changes can be seen in the lungs of
acquired immunodeficiency syndrome (AIDS) patients
receiving prophylaxis [76].
The Diagnosis of Extra-Pulmonary Invasive Fungal
Infections
CT is the method of choice in suspicion of IFIs in the
paranasal sinuses, and magnetic resonance imaging (MRI)
should be performed in cases of suspicion of central nervous
system involvement. Ultrasound, CT, or MRI can be used
for examining the abdomen in disseminated candidiasis;
typically small abscesses with a target-like appearance are
seen in the spleen and liver [82].
Interpretation
Although currently there are various opportunities in the
diagnosis of invasive fungal diseases, their implementation
is somewhat difficult. None of these tests can be used
to directly diagnose invasive fungal disease and they
generally carry more meaning when they are used together.
Radiological diagnosis seems to remain the most rapid and
351

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Arıkan Akdağlı S, et al: Diagnosis of IFI in Hematological Malignancies
easy method to use; however, it carries a risk of false positive
results. Serological tests such as GM, BG, and Mn/A-Mn
are not available at all institutions and carry a risk of false
positive or negative results, and delays in reporting make it
difficult to use them in diagnosis. Molecular approaches are
not yet recommended, as they are not standardized, carry a
risk of false positive results, and do not have widespread use;
however, in the very near future they have the potential to
hold an important place in diagnosis.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/
or affiliations relevant to the subject matter or materials
included.
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356

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DOI: 10.4274/tjh.2013.0091
The Relationship between P-Selectin Polymorphisms
and Thrombosis in Antiphospholipid Syndrome: A Pilot
Case-Control Study
Antifosfolipid Sendromunda P-Selectin Polimorfizmi ile Tromboz
arasındaki İlişki: Pilot Olgu Kontrol Çalışması
Nilüfer Alpay 1 , Veysel Sabri Hançer 2 , Burak Erer 1 , Murat İnanç 1 , Reyhan Diz-Küçükkaya 3
1İstanbul University İstanbul Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, İstanbul, Turkey
2İstanbul Bilim University Faculty of Medicine, Department of Medical Biology and Genetics, İstanbul, Turkey
3İstanbul Bilim University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, İstanbul, Turkey
Abstract:
Objective: The selectins are cell adhesion molecules that mediate the interactions among leukocytes, activated platelets, and
endothelial cells. We aimed to investigate whether P-selectin polymorphisms are associated with thrombosis in patients with
antiphospholipid syndrome (APS).
Materials and Methods: The diagnosis and classification of APS were based on the report of an international workshop.
Genomic DNA was extracted from citrated blood samples of all subjects. Three single nucleotide polymorphisms associated
with the P-selectin coding region (S290N, c.1087G>A; N562D, c.1902G>A; T715P, c.2363A>C) were assessed.
Results: There were 26 APS (65%) patients with thrombosis. The number of patients without thrombosis was 14 (35%).
The frequency of the N562D-DN genotype was significantly higher in patients with APS than in healthy controls (p=0.003).
The frequency of this genotype was significantly higher in patients with APS with thrombosis compared with patients with no
thrombosis (p=0.03). The N562D-NN genotype was found at a higher frequency in patients with APS than in healthy controls
(p=0.004).
Conclusion: Our results suggest that the N562D polymorphism of the DN genotype of P-selectin is associated with an
increased risk of thrombosis in patients with APS.
Key Words: P-selectin polymorphisms, Thrombosis, Antiphospholipid syndrome
Özet:
Amaç: Hücre adezyon molekülü olan selektinler, lökositlerle, aktive plateletler ya da endotel hücreleri arasındaki etkileşime
aracılık eder. Bu çalışmada antifosfolipid sendromu (AFS) hastalarında tromboz riski ile P-selektin polimorfizmleri arasındaki
ilişkinin araştırılması amaçlanmaktadır.
Address for Correspondence: Nilüfer ALPAY, M.D.,
İstanbul University İstanbul Faculty of Medicine, Department of Internal Medicine, Division of Rheumatology, İstanbul, Turkey
Phone: +90 212 414 20 00 E-mail: nalpay@istanbul.edu.tr
Received/Geliş tarihi : March 15, 2013
Accepted/Kabul tarihi : October 4, 2013
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Alpay N, et al: P-Selectin Polymorphisms and Thrombosis in Antiphospholipid Syndrome
Gereç ve Yöntemler: AFS tanısı “International Workshop” tanı ve sınıflandırma kriterleri ile konulmuştur. Hastaların
periferik kan örneklerinden DNA elde edilmiştir. P-selektin gen bölgesiyle ilişkili üç tane tek nükleotid polimorfizmi (S290N,
c.1087G>A; N562D, c.1902G>A; T715P, c.2363A>C) araştırılarak genotipleri belirlenmiştir.
Bulgular: Hasta grubunda 26 trombozlu (%65) AFS olgusu ve 14 (%14) trombozu olmayan AFS olgusu yer almaktadır. Hasta
ve kontrol grubu kıyaslandığında incelenen polimorfizmlerden N562D-DN genotipi hasta grubunda anlamlı olarak yüksek
bulunmuştur (p=0,003). Yine hasta grubuna bakıldığında trombozlu AFS grubunda trombozu olmayan AFS grubuna kıyasla
N562D-DN genotipine anlamlı olarak sık rastlanmıştır (p=0,03). N562D NN genotipi ise kontrol grubunda hasta grubuna
oranla daha yüksek sıklıktadır (p=0,004).
Sonuç: P-selektin N562D polimorfizmi DN genotipi primer AFS hastalarında tromboz riski ile ilişkili olduğu söylenebilir.
Anahtar Sözcükler: P-selektin polimorfizmleri, Tromboz, Antifosfolipid sendrom
Introduction
Antiphospholipid syndrome (APS) is an autoimmune
disease characterized by pregnancy morbidity and arterialvenous
thrombosis in the presence of antiphospholipid
antibodies (aPLAs) [1]. Although the relationship between
aPLAs and thrombosis is known, the mechanisms of
thrombosis in APS has not been fully elucidated. Selectins,
which are cell adhesion molecules, mediate the interactions
among leukocytes, activated platelets, and endothelial cells.
P-selectin, which can be identified as a soluble form in plasma,
intercedes in the attachment and rolling of leukocytes on
activated endothelial cells and is involved in the recruitment
of leukocytes to thrombi [2,3]. Novel data suggest that the
levels of soluble P-selectin (sP-selectin) are increased in
APS patients with thrombosis [4]. In this study, we aim to
investigate whether P-selectin polymorphisms are associated
with thrombosis in patients with APS.
Materials and Methods
Patients and Controls
Forty adult patients with APS and 40 healthy subjects
with no history of thrombosis or autoimmune disease
were included in the study. The history of disease, physical
examination, and screening of lupus anticoagulant (LA) and
serum anticardiolipin IgG and IgM levels were assessed for
all patients. The diagnosis and classification of APS were
based on an international consensus statement [1]. The
subjects participating in the study had no LA and/or serum
anticardiolipin-related systemic diseases or risk factors such
as hypertension or hyperlipidemia for thrombosis.
LA was diagnosed using activated partial thromboplastin
time, kaolin clotting time, and Russell’s viper venom
test according to published criteria [5]. IgG and IgM
anticardiolipin antibodies were determined by enzyme-linked
immunosorbent assay [6], and levels equal to or greater
than 4 standard deviations were regarded as positive. The
anticardiolipin antibody and LA tests were repeated 3 months
after the first determination. APS patients with thrombosis had
arterial and/or venous thrombosis as well as aPLA positivity.
aPLA-positive patients with no thrombosis suffered from
either first trimester fetal losses or thrombocytopenia and
had persistently positive aPLA test results but no thrombotic
complications over at least 3 years of follow-up.
The study protocol was approved by the local ethics
committee, and written and signed informed consent was
obtained from all participants.
Genotyping
Genomic DNA was extracted from citrated blood samples.
Three single nucleotide polymorphisms associated with
the P-selectin coding region (S290N, c.1087G>A; N562D,
c.1902G>A; T715P, c.2363A>C) were assessed. Polymerase
chain reaction (PCR) was done in a total volume of 25 µL
containing 2 U of Taq DNA polymerase (Fermentas), 2
mmol/L MgCl 2 , 0.2 mmol/L of each dNTP, 2.5 µL of 10X PCR
buffer, and 50 ng of genomic DNA.
Allele specific primers were used in the
following concentrations: 15 pmol of 290N-R
(5’-TAAATGAATTCAGTCCATGGTTCCTACAT-3’), 5 pmol
of 290S-R (5’-CACAGTCCATGGTTCCTTGAC-3’), 11 pmol of
290common (5’-TGTGTGGCTTTTCTCCTTTC-3’), 2 pmol of
562D-R (5’-ATTGCCCTACCAGCTTAAAGCCG TAGTC-3’),
7 pmol of 562N-R (5’-CTCCAGCTTAAAGCCGTTCTT-3’),
10.5 pmol of 562common (5’-TGAATATATAAGTGA
ATGAACTTTGTG-3’), 3.5 pmol of 715P-R (5’-CCT GCT
TGATAG GTT GCC ACG GAA GG-3’), 8 pmol of 715T-
R (5’-GCAGGT TGG CAC GGT TGT-3’), and 9 pmol of
715common (5’-CTGTGA AAT GCT CAG AAC TAC ATG-
3’). PCR amplification was carried out in a GeneAmp PCR
System 9700 Thermo Cycler (Applied Biosystems, USA) using
36 cycles of 94 °C for 25 s, 57 °C for 25 s, and 72 °C for 25 s.
PCR products were separated on agarose gels and stained with
ethidium bromide. The PCR products were 115, 205, and 182
bp long for S290N, N562D, and T715P, respectively.
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Alpay N, et al: P-Selectin Polymorphisms and Thrombosis in Antiphospholipid Syndrome
Turk J Hematol 2014;31:357-362
Statistical Analysis
Data are expressed as mean ± SD, number (%), or median
(range). Test statistics were computed using the Mann-
Whitney U test and the Kruskal-Wallis test. The chi-square
test and odds ratio were used to calculate the 95% confidence
intervals. Correlation coefficients and significance were
calculated by Spearman’s test to assess the differences between
groups. For all tests, a 2-tailed p-value of

Turk J Hematol 2014;31:357-362
Alpay N, et al: P-Selectin Polymorphisms and Thrombosis in Antiphospholipid Syndrome
Table 2. The frequency of S290N, N562D, and T715P polymorphisms in the patients and control groups.
SNP Rs Number Genotype All Patients
(n=40)
Patients with
Thrombosis
(n=24)
Patients without
Thrombosis
(n=16)
Control
(n=40)
S290N rs6131 (G>A) SS 21 (52%) 15 (62%) 6 (38%) 25 (63%)
SN 19 (48%) 9 (38%) 10 (62%) 13 (32%)
NN None None None 2 (5%)
N562D rs6127 (G>A) DD 6 (15%) 2 (8%) 4 (25%) 8 (20%)
DN 30 (75%) 21 (88%) 9 (56%) 17 (42%)
NN 4 (10%) 1 (4%) 3 (19%) 15 (38%)
T715P rs6136 (A>C) TT 31 (77%) 18 (75%) 13 (81%) 32 (80%)
SNP: single nucleotide polymorphism.
TP 7 (18%) 5 (21%) 2 (13%) 8 (20%)
PP 2 (5%) 1 (4%) 1 (6%) None
vAdditionally, the relationship PSGL-1 VNRT polymorphisms
and risk of thrombosis in APS patients was shown by Diz-
Kucukkaya et al. [17]. The relationship between P-selectin
polymorphism and thrombosis in APS patients was shown for
the first time in our study. The c.1087G>A, c.1902G>A, and
c.2363A>C polymorphisms lead to S290N, N562D, and T715P
P-selectin gene variations, respectively. These variations are in
the genetic region encoding the repeated part of the P-selectin
gene and may be effective in binding P-selectin to PSGL-1.
Therefore, our data are valuable in order to determine risk
factors other than traditional ones for thrombosis in APS
despite the fact that we did not estimate sP-selectin levels.
In conclusion, our results suggest that the N562D
polymorphism DN genotype of P-selectin is associated with
an increased risk of thrombosis in patients with APS. The
NN genotype of the same polymorphism might be protective
against thrombosis in those patients. The effect of N562D
polymorphism on sP-selectin levels will be studied in future
work.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/
or affiliations relevant to the subject matter or materials
included.
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Alpay N, et al: P-Selectin Polymorphisms and Thrombosis in Antiphospholipid Syndrome
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Table 3. The differences in S290N, N562D, and T715P polymorphisms among groups (group 1: all patients, group 1a:
patients with thrombosis, group 1b: patients without thrombosis, group 2: control subjects).
SNP
S290N
N562D
T715P
SS;
p-value
OR
CI
SN;
p-value
OR
CI
Between Groups
1 and 2
0.24
0.6
0.2-1.6
0.12
1.8
0.7-4.6
NN;
p-value 0.24
-
DD;
p-value
OR
CI
DN;
p-value
OR
CI
NN;
p-value
OR
CI
TT;
p-value
OR
CI
TP;
p-value
OR
CI
PP;
p-value
OR
CI
0.38
0.7
0.2-2.2
0.003*
4.0
1.5-10.5
0.004*
0.1
0.05-0.6
0.50
0.8
0.2-2.5
0.50
0.8
0.2-2.6
0.24
-
-
Between Groups
1a and 2
0.60
1.0
0.3-2.8
0.78
0.8
0.2-2.3
0.38
-
0.29
2.7
0.5-14.2
0.001*
0.1
0.02-0.4
0.003*
13.8
1.6-112.9
0.75
1.3
0.3-4.4
0.58
0.9
0.2-3.3
0.37
-
-
SNP: single nucleotide polymorphism, OR: odds ratio, CI: confidence interval, *: statistically significant.
Between Groups
1b and 2
0.13
2.7
0.8-9.2
0.07
0.2
0.09-0.9
0.50
-
0.72
0.75
0.19-2.9
0.38
0.5
1.1-1.8
0.21
2.6
0.6-10.6
0.61
0.9
0.2-4.03
0.70
1.7
0.3-9.3
0.28
-
-
Between Groups
1a and 1b
0.11
2.7
0.7-10.2
0.11
0.3
0.09-1.3
-
0.16
0.2
0.04-1.7
0.03*
5.4
1.1-25.9
0.16
0.1
0.01-2.0
0.47
0.6
0.1-3.2
0.40
1.8
0.3-10.9
0.64
0.6
0.03-11.2
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362

Research Article
DOI: 10.4274/tjh.2013.0152
Serum Bcl-2 Levels in Patients with β-Thalassemia Minor:
A Pilot Study
β-Talasemi Minörlü Hastalarda Serum Bcl-2 Düzeyleri:
Pilot Çalışma
İrfan Yavaşoğlu 1 , Gökhan Sargın 2 , Gürhan Kadıköylü 1 , Aslıhan Karul 3 , Zahit Bolaman 1
1Adnan Menderes University Faculty of Medicine, Division of Hematology, Aydın, Turkey
2Adnan Menderes University Faculty of Medicine, Department of Internal Medicine, Aydın, Turkey
3Adnan Menderes University Faculty of Medicine, Department of Biochemistry, Aydın, Turkey
Abstract:
Objective: Anti-apoptotic proteins such as Bcl-2 and Bcl-xL may play a role in the survival of erythroid progenitor cells.
Information about these proteins in patients with β-thalassemia minor is limited. We aimed to determine the levels of serum
Bcl-2 in patients with β-thalassemia minor.
Materials and Methods: Ninety-seven patients (60 females and 37 males with mean age of 29±21 years) with β-thalassemia
minor were enrolled in this study. The diagnosis of β-thalassemia minor was based on whole blood counts, family history,
and HbA2 levels estimated by high-performance liquid chromatography. The control group comprised 23 healthy adults (17
females and 6 males with mean age of 58±9 years) without anemia. The levels of serum Bcl-2 were measured by enzyme-linked
immunosorbent assay. Mann-Whitney U tests were used in statistical evaluation and p0.05), these levels were higher in β-thalassemia minor patients than controls.
Conclusion: There are damaged beta chains in β-thalassemia minor. Therefore, it is expected that premature death of red
blood cells may occur due to apoptosis. The mean age of the control group was higher than that of the β-thalassemia minor
group; this may be why Bcl-2 levels were higher in the β-thalassemia minor group. It is known that older age constitutes a risk
for increased apoptosis. Other proteins (Bad, Bax, etc.) and pathways [CD95 (Fas) ligand] associated with apoptosis should
be evaluated in future studies including more patients.
Key Words: β-Thalassemia minor, Bcl-2, Apoptosis
Address for Correspondence: Gökhan SARGIN, M.D.,
Adnan Menderes University Faculty of Medicine, Department of Internal Medicine, Aydın, Turkey
Phone: +90 553 424 10 97 E-mail: gokhan_sargin@hotmail.com
Received/Geliş tarihi : April 29, 2013
Accepted/Kabul tarihi : July 19, 2013
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Yavaşoğlu İ, et al: Serum Bcl-2 Levels and β-Thalassemia Minor
Özet:
Amaç: Bcl-2 ve Bcl-xL gibi antiapoptotik proteinler eritroid progenitör hücrelerin yaşam süresinde rol oynayabilir. β-talasemi
minör hastalarda bu proteinler ile ilgili bilgiler sınırlıdır. Biz, β-talasemi minörlü hastalarda serum Bcl-2 düzeylerinin
belirlenmesi amaçladık.
Gereç ve Yöntemler: β-talasemi minör tanılı doksan yedi hasta (60 kadın ve 37 erkek, yaş ortalamaları 29±21 yıl) bu
çalışmaya dahil edildi. β-talasemi minör tanısı tam kan sayımı, aile öyküsü ve yüksek performanslı sıvı kromatografisine
dayanan HbA2 düzeyleri ile konulmuştur. Kontrol grubu anemisi olmayan 23 sağlıklı yetişkin (17 kadın ve 6 erkek, yaş
ortalaması 58±9 yıl) idi. Serum Bcl-2 düzeyleri ELISA yöntemi ile ölçüldü. İstatistiksel değerlendirmede Mann-Whitney U
testi kullanıldı ve p0.05), β-talasemi minörlü hastalarda bu seviyeler kontrol grubuna göre daha yüksekti.
Sonuç: β-talasemi minörde hasarlı beta zincirleri bulunmaktadır. Bu nedenle, kırmızı kan hücrelerinin erken ölümünün
apoptoz nedeniyle olması beklenmektedir. Kontrol grubunun yaş ortalaması talasemi taşıyıcılarından yüksektir, bundan dolayı
Bcl-2 düzeyleri β-talasemi minörde yüksek olabilir. İleri yaşın artmış apoptoz için bir risk oluşturtuğu bilinmektedir. Bu
nedenle, 40 yaş üzerindeki talasemi minörlülerde, kontrole göre Apoptoz ile ilişkili diğer protein (Bad, Bax, vb.) ve yolaklar
[CD95 (Fas) ligand] hasta sayısının daha fazla olduğu çalışmalarda değerlendirilmelidir.
Anahtar Sözcükler: β-Talasemi minor, Bcl-2, Apoptoz
Introduction
Translations or mutations of mRNA lead to a deficiency of
globin synthesis and thus cause thalassemia syndromes [1].
Thalassemia syndromes are inherited disorders that occur as
a result of abnormal synthesis of α/β-globin. Cytoplasmic
inclusion bodies (including unpaired globin molecules)
damage red blood cells. As a result, the life span of erythrocytes
is shortened [1,2].
Cell death is regulated by many intra- and extracellular
signals. The ratio of anti-apoptotic molecules (Bcl-xl, Mcl-1,
Bcl-w, A1, etc.) to apoptotic molecules (Bax, Bak, Bik, Bid,
etc.) determines the future of the cell [3]. The Bcl-2 protooncogene
is located on chromosome 18 and inhibits the
apoptotic pathway. Bcl-2 is an important molecule in the early
period of cell transformation [3,4].
In recent years, some studies have been published about
Bcl-2 genes to predict their role in the development of many
solid tumors. However, there are few studies about the
expression of Bcl-2 in patients with β-thalassemia minor [5].
In this study, we aimed to determine the levels of serum
Bcl-2 in patients with β-thalassemia minor.
Materials and Methods
Ninety-seven patients (60 females and 37 males with mean
age of 29±21 years) with β-thalassemia minor were enrolled in
this study. The diagnosis of β-thalassemia minor was based on
whole blood counts, family history, and HbA2 levels estimated
by high-performance liquid chromatography (Agilent 1100
Series HPLC Value System, Waldbronn, Germany). The control
group comprised 23 healthy adults (17 females and 6 males
with mean age of 58±9 years) without anemia. The levels of
serum Bcl-2 were measured using a commercial enzyme-linked
immunosorbent assay kit (Biosource, Cat. No. TMA 0311,
Camarillo, CA, USA). Age, sex, hemoglobin, hematocrit, mean
corpuscular volume (MCV), whole blood cell counts, and
serum levels of Bcl-2 were recorded. Venous blood samples
were taken under the supervision of medical personnel and
were measured with an ADVIA 2120 instrument (Siemens,
Erlangen, Germany). Signed informed consent was obtained
from all participants. SPSS 15 (SPSS Inc., Chicago, IL, USA) and
the Mann-Whitney U test were used in statistical evaluation of
data and p0.05), levels in
β-thalassemia minor patients were higher than in the controls.
Bcl-2 levels of the patients with β-thalassemia minor and the
control group are shown by dot-plot distribution in Figure 1.
The relationships between age, hemoglobin, and MCV values
and serum Bcl-2 levels are shown in Table 2.
We evaluated serum Bcl-2 levels of 22 controls and 27
patients with β-thalassemia minor of over 40 years. Bcl-2
levels were statistically significantly higher among patients
than in the control group (p=0.045).
Discussion
In this study, we did not find any significant difference in
Bcl-2 levels between patients with β-thalassemia minor and
controls.
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Turk J Hematol 2014;31:363-366
Antiapoptotic proteins (Bcl-2, Bcl-xL, and Mcl-1) are
necessary for the survival of erythroid precursor cells [6].
Proteins such as Bax and Bcl-xS trigger apoptosis of erythroid
cells. According to some studies, Bcl-2 and Bax genes may
be regulated by the p53 gene. If the ratio of anti-apoptotic
proteins to pro-apoptotic proteins is more than 1, erythroid
cells continue their life span [7]. Additionally, members of the
Bcl-2 family may control apoptosis by acting as pro-oxidant
agents [8].
Erythropoietin increases Bcl-xL expression in erythroid-
CFU colonies [5]. Significantly increased Bcl-xL and Mcl-1
protein levels and the suppression of Bax protein are observed
in CD34 (+) cells, induced by erythropoietin or stem cell
factor [9]. Myelodysplastic syndrome (MDS) is characterized
with ineffective erythropoiesis and increased apoptosis of
hematopoietic precursor cells. A correlation was observed with
increased proteins associated with Bcl-2, but the mechanism is
not yet fully understood [10].
Levels of Bad, Bax, and Bcl-xS were especially higher in
patients with MDS-refractory anemia (RA) or RA with ring
sideroblasts [10]. Many changes in oncogenes and tumor
suppressor genes may have a role in the pathogenesis of many
diseases. Bcl-2 is located in the nucleus or membranes of the
endoplasmic reticulum, while mitochondria were shown to
be in neoplastic cells in B-cell neoplasms with t(14;18). The
mechanism of Bcl-2 activation is still unknown; however,
increased levels of cytochrome-c as a center of apoptosis may
play a role [11]. Hockenbery et al. reported that Bcl-2 inhibits
apoptosis by changing mitochondrial functions [12].
Translations or mutations of mRNA lead to deficiency of
globin synthesis and thus cause thalassemia syndromes. It was
reported in many studies that some cancers may be treated
by regulation genes on pre-RNA and mRNA regions. Changes
in apoptotic or anti-apoptotic pathways may be a result of
genetic modulation [13].
β-Thalassemia is characterized by accelerated apoptosis
of erythroid precursor cells. In many studies, limited data
were reported about these proteins and genetic mechanisms
in patients with thalassemia [2,3,4,5]. Increased synthesis of
fetal hemoglobin may improve the symptoms of β-thalassemia.
Cytotoxic drugs such as hydroxyurea and cytarabine may affect
the synthesis of fetal hemoglobin by stimulating precursor
cells [1]. Castaneda et al. determined that short-chain fatty
acids [arginine butyrate, sodium α-methylhydrocinnamate,
sodium 2,2-dimethylbutyrate, sodium 3,4-(methylenedioxy)
cinnamate, 2-(quinazolin-4-ylamino) butanoic acid, and
4-(trifluoromethyl) sulfanyl aniline acetic acid] increased
the erythroid-BFU colonies and endogenous fetal globin
gene expressions [5]. In addition, anti-apoptotic genes were
specifically regulated and Bcl-2 levels were increased by
short-chain fatty acids. It is known that increased apoptosis is
observed with older age [14].
Cao et al. reported that neutrophils of patients with
paroxysmal nocturnal hemoglobinuria expressed apoptosisrelated
CD95, Bcl-2, and Bax without significant differences
from the normal controls [15]. The results of a study by
Ismail et al. suggest a more significant role for Bcl-x as an antiapoptotic
regulator in CD34 (+) cells in aplastic anemia than
Bcl-2 [16].
The limitations of our study were the existence of an
age gap between the 2 groups and a limited number of
Bcl-2
36.00
34.00
32.00
30.00
32.74
34.28
Controls Thalessemia minor
Groups
Figure 1. Serum Bcl-2 levels with dot-plotdistribution.
Table 1. Hemoglobin, mean corpuscular volume, and serum Bcl-2 levels in patients with β-thalassemia minor and the
control group.
Hemoglobin (g/dL)
β-Thalassemia Minor
(n=97)
Female
(n=60)
Male
(n=37)
Control
(n=23)
Female
(n=17)
9.9±1.2 13.1±0.8 12.6±1.3 15.4±1.4
p-Value
Male
(n=6)

Turk J Hematol 2014;31:363-366
Yavaşoğlu İ, et al: Serum Bcl-2 Levels and β-Thalassemia Minor
Table 2. The comparison of serum Bcl-2 levels between
age and mean corpuscular volume groups.
Age of more than 40 years
Control (n=22)
β-Thalassemia minor (n=27)
Hemoglobin levels
≥11.4 g/dL (n=41)

Research Article
DOI: 10.4274/tjh.2013.0075
Duffy and Kidd Genotyping Facilitates Pretransfusion
Testing in Patients Undergoing Long-Term
Transfusion Therapy
Uzun Süreli Transfüzyon Tedavisi Alan Hastalarda Duffy ve Kidd
Genotiplendirme Transfüzyon Öncesi İncelemeleri Kolaylaştırıyor
Diana Remeikiene 1 , Rasa Ugenskiene 2 , Arturas Inciura 3 , Aiste Savukaityte 2 , Danguole Raulinaityte 2 ,
Erika Skrodeniene4, Renata Simoliuniene 5 , Elona Juozaityte 3
1Lithuanian University of Health Sciences, Institute of Oncology, Department of Haematology, Kaunas, Lithuania
2Lithuanian University of Health Sciences, Institute of Oncology, Oncology Research Laboratory, Kaunas, Lithuania
3Lithuanian University of Health Sciences, Institute of Oncology, Department of Oncology, Kaunas, Lithuania
4Lithuanian University of Health Sciences, Department of Laboratory Medicine, Kaunas, Lithuania
5Lithuanian University of Health Sciences, Department of Physics, Mathematics, and Biophysics, Kaunas, Lithuania
Abstract:
Objective: Conventional serologic typing of red blood cell systems other than ABO and RhD can be inaccurate and difficult
to interpret in patients who have recently undergone blood transfusion. While molecular-based assays are not used routinely,
the usefulness of genotyping was investigated in order to determine patients who may benefit from this procedure.
Materials and Methods: Blood samples were taken from 101 patients with haemato-oncological, chronic renal, or
gastroenterological diseases and from 50 donor controls; the samples were tested for Fy a and Fy b by applying serologic and
genetic methods. All patients had received 3 or more units of RBCs during the last 3 months. An average of 6.1 RBC units were
transfused per patient. The average length of time from transfusion until blood sampling was 24.4 days. The haemagglutination
test was applied for serological analysis, and the restriction length polymorphism assay was used for genotyping.
Results: In total, 33 (32.7%) patients showed positive reactions with anti-Fy a or anti-Fy b while being negative genetically. Falsepositive
Fy a results were found in 23 samples, and false-positive Fy b in 10 specimens. During the last 3 months, significantly
more RBC units were transfused to patients with discrepant results than to those with accurate phenotyping/genotyping results:
median of 5 (mean ± SE: 6.85±0.69) versus median of 4 (mean: 5.71±0.51), respectively (p=0.025). The median length of time
after the last transfusion was 25 days (mean: 28.72±2.23 days) in the group with accurate phenotyping/genotyping results
versus a median of 14 days (mean: 15.52±1.95 days) in the group with discrepant results (p=0.001). Phenotypes and genotypes
coincided in all donor samples.
Conclusion: Genotyping assays for the Duffy system should be considered if the patient underwent blood transfusion less
than 3 or 4 weeks before the sample collection. If the time frame from RBC transfusion exceeds 6 weeks, Duffy phenotyping
can provide accurate results.
Key Words: Duffy phenotyping, Kidd phenotyping, Genotyping, Multitransfused patients
Address for Correspondence: Diana REMEIKIENE, M.D.,
Lithuanian University of Health Sciences, Institute of Oncology, Department of Haematology, Kaunas, Lithuania
Phone: +370 37326303 E-mail: diana.remeikiene@kaunoklinikos.lt
Received/Geliş tarihi : February 28, 2013
Accepted/Kabul tarihi : November 1, 2013
367

Turk J Hematol 2014;31:367-373
Remeikiene D, et al: Duffy and Kidd Genotyping for Transfusions
Özet:
Amaç: Eritrositlerin ABO ve RhD sistemleri dışındaki konvansiyonel serolojik tiplendirmesini son zamanlarda sık kan
transfüzyonu yapılmış olan kişilerde yorumlamak yanlış ve zor olabilir. Bazı moleküler incelemeler henüz rutin olarak
kullanılmamasına rağmen, genotiplendirmenin yararı bu işlemden fayda görecek hastaları belirlemek amacıyla incelenmiştir.
Gereç ve Yöntemler: Hemato-onkoloijk, kronik böbrek hastalığı veya gastrointestinal hastalığı olan 101 hastadan ve kontrol
grubu olan 50 kişiden karşılaştırmak üzere kan örnekleri alındı. Numuneler serolojik ve genetik yöntemler kullanılarak Fy a ve Fy b
için test edildi. Bütün hastalara son 3 ay içinde 3 ve daha fazla ünite eritrosit süspansiyonu transfüzyonu yapılmıştı. Her hasta için
ortalama transfüzyon 6,1 ünite olarak hesaplandı. Transfüzyondan örneklerin alınmasına kadar geçen ortalama süre 24,4 gündü.
Hemaglütinasyon testi serolojik analiz için uygulandı, ve uzunluğu kısıtlanmış polimorfizm testi genotipleme için kullanıldı.
Bulgular: Genetik olarak negatif olan, toplam 33 (%32,7) hastada anti-Fy a veya anti-Fy b ile pozitif reaksiyon elde edildi. Yirmi üç
örnekte yanlış pozitif Fy a sonucu, 10 örnekte yanlış pozitif Fy b sonucu elde edildi. Son 3 ayda fenotiplendirme/genotiplendirme
sonuçları tutarsız olanlarda uyumlu olanlara göre anlamlı olarak daha fazla eritrosit süspansiyonu transfüzyon yapılmıştı: sırasıyla
ortanca 5 (ortalama ± SE: 6,85±0,69) ve ortanca 4 (ortalama ± SE: 5,71±0,51) (p=0,025). Fenotiplendirme/genotiplendirmesi
sonuçları uyumlu olan grupta transfüzyondan test aşamasına kadar geçen ortanca süre 25 gün (ortalama: 28,72±2,23) iken,
sonuçları uyumsuz çıkan grupta bu süre ortanca 14 (ortalama: 15,52±1,95) gündü. Tüm donör örneklerinde fenotip ve genotipler
tutarlıydı.
Sonuç: Örnek alınmasından 3 veya 4 hafta öncesinde transfüzyon alan kişilerde Duffy sistemi için genotiplendirme yapılması
uygun olabilir. Eğer eritrosit süspansiyonu transfüzyonundan sonra geçen süre 6 haftadan fazla ise, Duffy fenotiplendirmeyle
uygun ve güvenilir sonuçlar sunabilir.
Anahtar Sözcükler: Duffy fenotiplendirme, Kidd fenotiplendirme, Genotiplendirme, Çoklu transfüzyon alan hastalar
Introduction
Patients who require multiple transfusions of red blood
cells (RBCs), such as those with sickle cell disease (SCD) or
β-thalassaemia, have a higher potential risk of alloimmunisation
and delayed haemolytic transfusion reactions (DHTRs). The
widely described risk of developing antibodies, mostly to
Rh, Kell, Duffy, Kidd, and MNS systems, ranges from 18% to
47% [1,2]. Programs to prevent alloimmunisation have been
implemented in the centres treating patients with SCD and
β-thalassaemia [1,3,4]. In addition to ABO and RhD matching,
protocols range from providing limited antigen-matched
RBCs for Rh and Kell to extended antigen-matched RBCs for
Rh, Kell, Duffy, Kidd, and MNS systems prior to transfusion.
Accurate phenotyping of multitransfused patients is
often complicated, mostly due to the presence of circulating
transfused donor RBCs in the recipient’s blood, leading to
discrepancies in the assessment of tests results. The importance
of the genotyping of clinically relevant antigens (such as C, c,
E, K, Fya, Fy b , Jk a , Jk b , and S) in addition to phenotyping
is still being discussed for patients with SCD, β-thalassaemia,
and other haemoglobinopathies.
However, there is a lack of information about the need
for molecular testing for other groups of patients who
depend on long-term RBCs transfusions, such as those with
myelodysplastic syndrome, myelofibrosis, or chronic renal
failure [5,6,7]. Delayed haemolytic transfusion reactions are
often an issue in these patients, affecting their quality of life
and sometimes being fatal. The selection of antigen-negative
RBCs in order to reduce alloimmunisation is often required
for patients with long-term transfusions and for those with
formed alloantibodies.
The most common causes of DHTR include antibodies
against Rh, Kell, Kidd, Duffy, and MNS systems [3,8,9,10].
Serological testing and evaluation of the antigens and
antibodies of the Duffy and Kidd systems are among the
main problems in multitransfused patients. The correlation
between serological and molecular typing of Duffy and Kidd
systems demonstrates the benefits of genotyping in patients
who depend on chronic RBC transfusions.
The aim of our study was to estimate the value of DNAbased
typing of Duffy and Kidd systems in chronically
transfused non-SCD or β-thalassaemia patients, and to
establish the impact of the amount of transfused RBCs and
the time from the last transfusion on the discrepancy of the
results.
Materials and Methods
Patients
Peripheral blood samples were obtained from 101 patients
with haematological and oncological diseases, chronic renal
failure, and gastrointestinal diseases. All patients received 3 or
more units of RBCs during the last 3 months. The inclusion
criteria were the time frame from the last RBC transfusion
being shorter than 8 weeks and the need for further
368

Remeikiene D, et al: Duffy and Kidd Genotyping for Transfusions
Turk J Hematol 2014;31:367-373
transfusions. None of the patients were tested for Fy a , Fy b ,
Jk a , or Jk b antigens before transfusions.
Most of the RBC units received by the haematology
patients and some of those received by the oncology patients
were leucodepleted, while others were non-leucodepleted.
Thus, 62 patients (61.4%) were transfused with leucoreduced
RBCs, and 39 (38.6%) with entirely (or by more than half)
non-leucoreduced RBCs. The median number of transfusion
events per patient was 3 (mean: 3.33±0.21, range: 1-12). A
median of 2 (mean: 1.85±0.04, range: 1-4) RBC units were
administered per transfusion event and 4 (mean: 6.1±0.41,
range: 3-24) units per patient.
Donors
In total, 49 blood donors served as controls in our study.
Blood samples of donors were obtained by taking 1 or 2
segments of tubes from RBC bags used for transfusions. This
control group and the patient group were used to determine
frequencies of Duffy and Kidd phenotypes in a Lithuanian
population.
Blood samples of all patients and donors were tested for
Fya, Fy b , Jk a , and Jk b antigens by applying serological and
molecular methods. Approval for the study was obtained from
the Regional Bioethics Committee.
Serotyping
Peripheral blood samples were used for Duffy and Kidd
phenotyping. Fya, Fy b , Jk a , and Jk b antigens were determined
by haemagglutination using anti-Fy a , anti-Fy b , anti-Jk a ,
and anti-Jk b Coombs reactive (polyclonal, human) reagents
(Antitoxin GmbH, Germany) and DG Gel Coombs cards
(Diagnostic Grifols, S.A., Spain). Each microtube of the
card contained polymerised dextran in a buffered medium
containing preservatives and low ionic strength solution,
and was mixed with polyspecific anti-human globulin.
The tests were performed according to the manufacturer’s
recommendations. The results of the agglutination were
expressed by using plus/minus values. Positive results were
evaluated from 1+ to 4+.
Genotyping
The DNA was extracted from peripheral blood leucocytes
using a DNA extraction kit (GeneJet Genomic DNA
Purification Kit, Thermo Fisher Scientific, USA), following the
manufacturer’s instructions. Polymorphism was identified by
polymerase chain reaction-restriction length polymorphism
(PCR-RFLP) analysis according to Reid et al. [7]. Briefly,
each PCR reaction was carried out in a total volume of 25 µL
containing 1X DreamTaq standard buffer, template DNA, 50
pM of each primer, 2.0 mM MgCl 2 , 200 µM of each dNTP, and
1 U of DreamTaq DNA polymerase (Thermo Fisher Scientific)
with annealing at 62 °C.
The amplification products were then digested overnight
by restriction endonuclease BanI (Thermo Fisher Scientific),
following the manufacturer’s instructions. The fragments were
separated electrophoretically using 2% agarose gel containing
ethidium bromide.
The Duffy antigen is present in 2 major allelic forms,
FY*A and FY*B, differing in an amino acid at position 42
(Gly42Asp) of the Duffy antigen receptor. The amino acid
Table 1. The results of Duffy and Kidd system phenotyping
and genotyping in 101 multitransfused patients.
Genotype
Phenotype
Combination of FY alleles Fy (a+b-) Fy (a+b+) Fy (a-b+)
FY*A/FY*A 7 10 0
FY*A/FY*B 0 53 0
FY*B/FY*B 0 23 8
Combination of JK alleles
JK*A/JK*A 6 20 0
JK*A/JK*B 0 52 0
JK*B/JK*B 0 12 11
Kappa 0.368, p

Turk J Hematol 2014;31:367-373
Remeikiene D, et al: Duffy and Kidd Genotyping for Transfusions
change occurs because of G125A polymorphism in the Duffy
antigen receptor for the chemokine gene (DARC).
The Kidd antigen system is known to comprise 2
major alleles, JK*A and JK*B, which result from a single
nucleotide polymorphism (838G→A) in gene SLC14A1.
The corresponding JK*A and JK*B antigens differ by a single
amino acid (D280N).
Statistical Analysis
The comparison of medians between the groups was
performed by applying the nonparametric Mann-Whitney U
test. We did not compare the means because the values of the
studied variables were not normally distributed (Kolmogorov-
Smirnov test, p

Remeikiene D, et al: Duffy and Kidd Genotyping for Transfusions
Turk J Hematol 2014;31:367-373
into 2 groups. The first group included those who received
RBCs less than 4 weeks before and the second group more
than 4 weeks before the sample collection. The influence of
the number of transfused RBCs on the disagreement of the
results was also analysed.
Duffy System
A total of 33 (32.7%) phenotype/genotype discrepancies
were assessed. However, in samples that did not contain one
of the Duffy antigens, discrepant results were found in 68.8%
of cases.
Significant differences in phenotype/genotype
disagreements between the 2 aforementioned groups were
found in 29 and 4 cases, respectively (Table 2).
The comparison of the duration of time after the last
transfusion between the 2 groups of patients with accurate
and discrepant phenotype/genotype results also showed
a significant difference. The median of days after the last
transfusion was found to be 14 (mean: 15.52±1.95) in the
group with discrepant results versus 25 (mean: 28.72±2.23)
in the group with accurate results (p=0.001).
No effect of transfused RBCs per year on Duffy phenotyping
and genotyping discrepancies was detected: 605 units
[median:5 (mean: 8.91±1.58, range: 3-46)] were transfused
to patients with accurate phenotype/genotype results, and 294
units [median: 6 (mean: 8.91±1.4, range: 3-81] to those with
discrepant results (p=0.207).
Significantly different results were found when comparing
the number of RBC units transfused during the last 3 months
between the 2 aforementioned groups. A median of 5 (mean:
6.85±0.69) units were transfused during this period to the
patients with discrepant phenotype/genotype results versus
4 (mean: 5.71±0.5) to those with accurate results (p=0.025).
Kidd System
Disagreements between genotyping and serologic typing
for Jka/Jk b were found in 32 (31.7%) blood samples, while
in samples that did not contain one of the Kidd antigens,
discrepant results were found in 65.3% of cases.
Significantly more discrepant phenotype/genotype results
were found in the samples of patients of the first group than
in those of the second group, at 27 and 5 cases, respectively
(Table 3).
The time after the last transfusion was shown to be
significantly different between the 2 groups of patients. The
median of days after the last transfusion was found to be
10.5 (mean: 16.09±2.45) in the group with discrepant results
versus 25 (mean: 28.26±2.13) in the group with accurate
results (p=0.01).
No effect of the transfused RBCs per year on Kidd
phenotyping and genotyping discrepancies was detected:
649 units [median: 5 (mean: 9.41±1.66, range: 3-81)] were
transfused to patients with accurate phenotype/genotype
results, and 250 units [median: 8 (mean: 7.84±0.72, range:
3-18)] to those with discrepant results (p=0.188). There was no
difference with regard to the number of RBC units transfused
during the last 3 months between the 2 aforementioned
groups, either. A median of 6 (mean: 6.28±0.48) units were
transfused during this period to the patients with discrepant
phenotype/genotype results versus a median of 4 (mean:
5.99±0.56) to those with accurate results (p=0.71).
Phenotype Frequencies
Genotyping results were used to determine the expected
Duffy and Kidd phenotype frequencies. No differences were
found when comparing these results with those of other
authors [8,9]. The phenotypes of 101 patients and 49 controls
are presented in Table 4.
Discussion
It is still disputable which situations require extended
typing of transfused RBCs beyond routine matching for
ABO, RhD, and existing antibodies. Although a number
of studies found that SCD or β-thalassaemia patients may
benefit from extended antigen matching, there is still a
lack of recommendations in this context for other patients
undergoing long-term RBC transfusions [1,11,12].
Additional antibodies are known to occur in 20% to 90%
of previously alloimmunised patients [13,14,15]. Schonewille
et al. evaluated the incidence of new antibody formation with
subsequent transfusion in 22% of alloimmunised haematooncology
patients and in 20%-25% of the non-haematology/
oncology cohort [14,15]. The transfusion of extended
antigen-matched RBCs, including Duffy and Kidd systems,
has been shown to lower alloimmunisation in about 70%
of cases [16,17]. According to these studies as well as those
investigating SCD patients, extended antigen matching could
be recommended for haemato-oncology patients and other
subjects who undergo long-term transfusions.
We agree with the many authors who state that antigen
typing of recently transfused patients is not always accurate, as
their peripheral blood contains transfused cells [5,6,13,18,19].
Several reports describe this type of discrepancy in up to
10% of cases for the Duffy and Kidd systems by comparing
phenotyping and genotyping results [6,18,20]. These findings
differ from our data, which showed a much higher rate
of discrepancies (32.7% and 31.7%), although the results
cannot be accurately compared because other authors failed
to provide information about the number of transfused RBC
units or the time frame from the last transfusion.
In contrast to a number of previous studies [6,18,20,21,22],
our data do not suggest the presence of additional Duffy
system alleles (which are known to be associated with
reduced or abolished gene expression) either in patients or in
371

Turk J Hematol 2014;31:367-373
Remeikiene D, et al: Duffy and Kidd Genotyping for Transfusions
donors. This is likely due to the fact that only genotypes of the
Caucasian population were tested in our study.
The phenotyping/genotyping results in a group of patients
who received transfusions within a time period of 7 days before
sample collection also differed from those reported earlier,
particularly for the Kidd system [5,7]. In this group, a total
of 24 samples in our study showed positive (2+ to 4+) results
for Fya, Fy b , Jk a , and Jk b , although genotypically, 14 of them
were Fya- or Fy b -negative, and 14 were Jk a - or Jk b -negative.
Reid et al. described concordant phenotype/genotype results
for 7 samples and mixed-field agglutination for 32 samples for
Duffy antigens; they also described coincident results for 16
samples and mixed-field agglutination for 31 samples for the
Kidd system [7].
Our data suggest the need for blood group genotyping
(including the Duffy and Kidd systems), which was proposed
by many authors [1,2,3,4,5,6,7,11,13,16,18,19,20,23,24,25].
Nevertheless, one should determine when genotyping should
replace serology or be combined with it for patients undergoing
long-lasting RBC transfusions. This is particularly important
for institutions that do not perform blood group genotyping
routinely. We found in our study that Duffy genotyping/
phenotyping disagreements depended on the number of
transfused RBC units during the last 3 months. However, it
would be difficult to predict how many units would cause
these discrepancies or to make specific recommendations.
The limitation of our study is the small number of subjects,
which complicated their grouping according to the number of
transfused RBC units.
The results of our study regarding the effect of the length
of time after the last transfusion on serology findings are
useful in clinical practice. A significantly lower number of
Duffy and Kidd phenotyping/genotyping discrepancies was
found in patients who underwent their last transfusions more
than 3 (p=0.01 and p=0.017, respectively) or 4 (p=0.003 and
p=0.018, respectively) weeks before the sample collection.
Only one disagreement for the Duffy system (compared to
3 for the Kidd system) was found when the time from the
last transfusion was from 6 to 7 weeks. No discrepancies
were found for either system when the last transfusion was
performed more than 7 weeks before.
Our data are also in agreement with previous reports
indicating that the range of agglutination in mixed-field
reactions does not predict the actual antigen typing [7]. For
example, 10 patients in the discrepant group with 2+ reaction
for Fya and 2+ or 3+ reaction for Fy b had FY*B/FY*B genotypes.
In the group with accurate results, 7 genotypically FY*A/
FY*B samples also showed 2+ agglutination with anti-Fya.
An exception could be made for serologic reactions with the
expression of 1+. All 5 of the 1+ reactions in the Duffy system
typing as well as 8 respective reactions in the Kidd typing
genetically showed no allele expression. Those reactions were
classified as serologically negative. More research is needed to
confirm this statement.
Conclusions
Our study showed that Duffy or Kidd phenotyping with
agglutination tests is inappropriate for patients who have
recently undergone blood transfusion. Genotyping should be
considered when the patient underwent transfusion less than
4 weeks before the sample collection. The group of patients
who recently (

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373

Research Article
DOI: 10.4274/tjh.2013.0004
Bone-Specific Alkaline Phosphatase Levels among
Patients with Multiple Myeloma Receiving Various
Therapy Options
Farklı Tedavi Rejimleri Alan Multipl Myelom Hastalarında Kemik
Spesifik Alkalen Fosfataz Düzeyleri
Güven Çetin 1 , Ahmet Emre Eşkazan 2 , M. Cem Ar 3 , Şeniz Öngören Aydın 4 , Burhan Ferhanoğlu 4 ,
Teoman Soysal 4 , Zafer Başlar 4 , Yıldız Aydın 4
1Bezmialem Vakıf University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, İstanbul, Turkey
2Diyarbakır Training and Research Hospital, Clinic of Hematology, Diyarbakır, Turkey
3İstanbul Training and Research Hospital, Clinic of Hematology, İstanbul, Turkey
4İstanbul University Cerrahpaşa Faculty of Medicine, Department of Internal Medicine, Division of Hematology, İstanbul, Turkey
Abstract:
Objective: This study aimed to investigate the impact of the different therapy regimens used in multiple myeloma (MM) on
bone-specific alkaline phosphatase (BALP) levels.
Materials and Methods: One hundred and thirteen patients with MM were included in the study. Patients were grouped
according to the regimens they received, as follows: group 1, melphalan and prednisolone (MP); group 2, vincristine, adriablastin,
and dexamethasone (VAD); group 3, thalidomide plus dexamethasone; and group 4, bortezomib plus dexamethasone. BALP
levels were measured before treatment and at the third and sixth months of treatment. A fifth group consisted of patients in
the post-treatment remission period at study entry (no-treatment group).
Results: The BALP levels at the third and sixth months of the treatment were significantly higher than the pre-treatment
levels in the bortezomib and the no-treatment groups, whereas no significant difference was observed in the MP, VAD, and
thalidomide groups.
Conclusion: Considering that BALP is a surrogate marker of bone formation, our study suggests that bortezomib more
efficiently leads to the improvement of bone disease in myeloma than other treatment options.
Key Words: Multiple myeloma, Bone-specific alkaline phosphatase, Bortezomib, Thalidomide
Özet:
Amaç: Bu çalışmanın amacı; multipl myelomda (MM) kullanılan farklı tedavi rejimlerinin kemik-spesifik alkalen fosfataz
(BALP) düzeyleri üzerine etkisini incelemektir.
Address for Correspondence: Güven ÇETİN, M.D.,
Bezmialem Vakıf University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, İstanbul, Turkey
Phone: +90 532 551 47 98 E-mail: drgvn@mynet.com
Received/Geliş tarihi : January 2, 2013
Accepted/Kabul tarihi : July 19, 2013
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Çetin G, et al: Multiple Myeloma and Bone-Specific Alkaline Phosphatase
Turk J Hematol 2014;31:374-380
Gereç ve Yöntemler: Çalışmaya 113 MM hastası dahil edildi. Hastalar aldıkları tedavi rejimlerine göre; 1. grup, melfalan
ve prednizolon (MP); 2. grup, vinkristin, adriablastin ve deksametazon (VAD); 3. grup talidomid artı deksametazon; 4. grup,
bortezomib artı deksametazon olarak gruplara ayrıldı. BALP düzeyleri tedaviden önce, tedavinin üçüncü ve altıncı aylarında
ölçüldü. Çalışmanın başında, tedavi sonrası remisyon dönemindeki hastalardan beşinci bir grup oluşturuldu (tedavi almayan
grup).
Bulgular: Bortezomib grubu ve tedavi almayan grupta tedavinin üçüncü ve altıncı aylarında bakılan BALP düzeyleri, tedavi
öncesine göre anlamlı olarak yüksek bulunurken; MP, VAD, ve talidomid gruplarında anlamlı fark saptanmadı.
Sonuç: BALP’nin kemik formasyonunun bir belirteci olduğu göz önünde tutulduğunda, bu çalışma ile diğer tedavi seçeneklerine
göre bortezomib tedavisinin miyelomda kemik hastalığının iyileşmesine daha etkin bir şekilde yol açtığı gösterilmiştir.
Anahtar Sözcükler: Multipl Myelom, Kemik Spesifik Alkalen Fosfataz, Bortezomib, Talidomid
Introduction
Multiple myeloma (MM) is a malignant disease
characterized by anemia, monoclonal protein in the serum
and/or the urine, osteolytic bone lesions, hypercalcemia,
and renal insufficiency resulting from uncontrollable clonal
hyperproliferation of plasma cells in bone marrow [1,2,3]. The
skeletal system problems that appear either at the time of the
diagnosis or during the progression of MM cause a decrease
in the quality of life and lead patients to present to health
services. The rate of skeletal system-related complications
including bone pain, osteolytic lesions, and pathological
fractures reaches up to 80% in patients with MM [4,5]. In the
studies concerning MM, it has been demonstrated that there
is a significant relation between the bone-specific alkaline
phosphatase (BALP) levels and bone pain, lytic lesions, and
bone fractures [1,2].
Until now, there has been no large study showing the effect
of various therapy options used in the treatment of MM on the
changes in bone metabolism caused by myeloma. The aim of
the present study was to investigate the relationship between
pre-treatment and post-treatment BALP levels and the therapy
options in patients with MM, and to expose the effect of these
therapy options on bone metabolism.
Materials and Methods
Patients
One hundred and thirteen patients diagnosed with MM
in accordance with the criteria of the International Myeloma
Working Group and followed in the Hematology Division of
the Internal Medicine Department of the İstanbul University
Cerrahpaşa Medical Faculty between November 2006 and July
2009 were included in the present study. The study cohort
consists of patients with MM that have been followed and/
or treated for at least 6 months regardless of their age, sex,
stage of the disease, and type of the therapy. Continuity of the
out-patient clinic visits for follow-ups was confirmed, and the
general status of the patients had not deteriorated. The study
was planned in accordance with the Helsinki Declaration,
and the approval of the Ethics Committee of the İstanbul
University Cerrahpaşa Medical Faculty was obtained. Written
informed consent of the patients to participate in the study
was received. Participants who chose to quit the study for any
reason, cases lacking any results from the analyses done for
the evaluations, cases of non-continuance of follow-up visits,
and patients who died before completing the follow-up period
were not included in the study.
Methods
The melphalan and prednisone (MP; group 1); vincristine,
adriamycin (doxorubicin), and dexamethasone (VAD; group
2); thalidomide (group 3); and bortezomib (group 4) regimens
were as defined before [6,7,8,9]. International Myeloma
Working Group response criteria were used while evaluating
the patients’ responses to these treatment modalities [10]. All
patients had received monthly zoledronic acid treatment, and
since the serum BALP values could be affected, the patients
with renal insufficiency who required dialysis were excluded
from the study population.
The levels of BALP (initial, third month, and sixth
month), serum protein electrophoresis, C-reactive protein,
erythrocyte sedimentation rate, lactate dehydrogenase,
total protein, albumin, hemoglobin, beta-2 microglobulin,
creatinine, glomerular filtration rate, calcium, quantitative
immunoglobulin and light chain, and immunofixation
electrophoresis of all patients were analyzed in the Fikret Biyal
Central Biochemistry Laboratory of the İstanbul University
Cerrahpaşa Medical Faculty.
Four milliliters of peripheral blood was taken from
all patients into tubes containing EDTA both prior to the
treatment and at the third and sixth months of treatment.
BALP levels were measured by means of radioimmunoassay
technique using the Ostease BALP Kit of International
Diagnostic Systems Ltd. The normal ranges of BALP levels
among pre-menopausal women, post-menopausal women,
and men are 11.6-29.6 U/L, 14.2-42.7 U/L, and 15.0-41.3 U/L,
respectively, as given by the manufacturer.
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Turk J Hematol 2014;31:374-380
Çetin G, et al: Multiple Myeloma and Bone-Specific Alkaline Phosphatase
Complete blood count was evaluated with a Beckman
Coulter HMX auto-analyzer in the laboratory of the
Hematology Division. Bone marrow aspiration and biopsies
were evaluated in the Pathology Department of Cerrahpaşa
Medical Faculty.
Statistical Evaluation
Statistical analyses were done with the NCSS 2007
package program. In addition to the descriptive methods
(mean, standard deviation), Friedman’s test was used for the
repetitive measurements of the multiple groups, the Kruskal-
Wallis test was used for intergroup comparisons, Dunn’s
multiple comparison test was used for the comparison of
sub-groups, and chi-square and Fisher’s exact tests were used
for the comparison of qualitative data. The level of statistical
significance was set at p

Çetin G, et al: Multiple Myeloma and Bone-Specific Alkaline Phosphatase
Turk J Hematol 2014;31:374-380
There was no significant difference according to the pretreatment,
third month, and sixth month mean BALP values
among the MP, VAD, and thalidomide groups (p=0.069,
p=0.148, p=0.254; Table 2). There was a significant change
between the pre-treatment, third month, and sixth month
mean BALP values in the bortezomib group (p=0.002). While
the sixth month mean BALP value was significantly higher
than the pre-treatment and third month mean BALP values
(p=0.003), no significant difference was found between pretreatment
and third month values (p>0.05). Significant change
was found between initial, third month, and sixth month mean
BALP values of the no-treatment group (p=0.0001) (Table 2).
The initial mean BALP values were found to be significantly
lower than the third and sixth month mean BALP values
(p=0.001, p=0.035). Since the patient numbers in the groups
were relatively small, especially when divided according to DS
stages, we did not compare BALP values among the patient
groups according to the DS staging system.
Discussion
Myeloma-induced skeletal problems negatively affect the
quality of life [11,12,13].
The activation of osteoclasts and the suppression of
osteoblasts are the main events in MM. Bone formation
is suppressed. Therefore, bone lesions are totally lytic in
patients with MM [14]. Osteoclasts usually proliferate on the
resorptive surfaces adjacent to the myeloma cells in the bone
and do not proliferate in the regions that do not have tumoral
involvement [15].
Until the new treatment options were developed, MP,
high-dose dexamethasone, VAD, and multi-drug combination
chemotherapies were the combinations most frequently used
in MM [16,17,18,19]. The new drugs that have recently been
included in the treatment of MM are molecular-targeted drugs
that target the micro-environment of the bone. Among those
drugs, good therapy responses have been obtained with the
combination of thalidomide, bortezomib, or lenalidomide with
high-dose dexamethasone [20]. The treatment of myeloma
bone disease has mainly been directed toward the inhibition
of osteoclastic activity with the use of bisphosphonates [11].
Anti-myeloma therapies that cause remission are usually
not accompanied by an increase in the osteoblast indicators or
in bone mineral density [21,22].
When compared with patients with monoclonal
gammopathy of undetermined significance or with the
healthy controls, deterioration in osteoblastic activity in the
patients with MM was observed with a decrease in osteocalcin
or BALP levels [23]. In healthy subjects, BALP accounts for
approximately 50% of the total alkaline phosphatase (TAP) in
the circulation. BALP reflects both the bone formation and the
bone degradation more sensitively than alkaline phosphatase
[24]. Serum BALP shows a remarkable correlation with the
dynamic parameters of bone formation [25].
The fact that there is a relationship between the increase
in serum BALP and osteoblastic activity in MM has been
demonstrated in another study, as well [26]. Some preclinical
trials again raised the suggestion that the inhibition of
proteasome might enhance osteoblastic activity [27]. From
this perspective, proteasome inhibitors represent a group of
new anti-tumor drugs [28] and have strong anti-myeloma
effects [29].
Bortezomib, which is a proteasome inhibitor, is the first
drug used in the treatment of MM that has similar effects on the
osteoblastic function together with important anti-myeloma
activity [11,14,15,30,31,32,33,34]. Bortezomib, a firstgeneration
proteasome inhibitor that has been developed to be
used as an anti-neoplastic agent, inhibits the 26S proteasome
that is located on the chymotryptic region and inhibits the
proliferation of chemotherapy-sensitive, chemotherapyresistant,
and dexamethasone-resistant MM cells as well as the
proliferation of MM cells that have been recently isolated from
the bone marrow of the patients [35,36].
The first evidence concerning the effect of bortezomib
on bone metabolism came from a 63-year-old female
patient with κ-chain MM who had undergone sequential
autologous transplantation and was then treated with
Table 2. The change in BALP values among different treatment groups (BALP: bone-specific alkaline phosphatase).
BALP MP VAD Thalidomide Bortezomib No-treatment KW p
value
(U/L)
group
(n=25)
group
(n=20)
group
(n=17)
group
(n=25)
group
(n=26)
Initial 32.73±32.19 34.54±20.89 21.64±8.54 21.87±14.11 24.26±14.99 9.79 0.069
Third month 27.42±12.69 34.94±20.61 26.17±17.29 23.2±12.89 29.96±16.18 6.78 0.148
Sixth month 22.96±10.69 33.16±19.78 27.63±17.68 28.75±13.12 28.43±13.64 5.34 0.254
Fr 2 0.7 4.507 12.48 15.431
p 0.368 0.705 0.105 0.002 0.0001
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Çetin G, et al: Multiple Myeloma and Bone-Specific Alkaline Phosphatase
1 mg/m 2 bortezomib on days 1, 4, 8, and 11 of a 21-day cycle.
The paraprotein response of myeloma was associated with a
rapid increase in TAP. The effect continued for a few therapy
cycles and the BALP values were normal during the relapses
[9,37]. Sezer et al. reported a negative correlation between
RANKL and osteoprotegerin [38]. Subsequently, a significant
increase was determined in BALP levels in the group receiving
bortezomib as compared to the control group, and this finding
was interpreted as osteoblastic activity increasing the effect
of bortezomib. Thereafter, the change in alkaline phosphatase
levels was retrospectively analyzed and evaluated in 2 large
studies (APEX and SUMMIT studies) in which bortezomib
was used as a single agent in patients with recurrent/refractory
MM [39,40]. Data obtained from all these studies show that
bortezomib increases osteoblastic activity.
In the present study, the initial, third month, and sixth
month BALP levels were not significantly different in the
MP, VAD, and thalidomide groups. Significant change was
observed among the pre-treatment, third month, and sixth
month mean BALP values of the bortezomib group. The sixth
month mean BALP value was found statistically higher than
the pre-treatment and third month mean BALP values.
Significant change was observed between the initial,
third month, and sixth month mean BALP values of the notreatment
group. The initial mean BALP value was found
statistically lower than the third and sixth month mean BALP
values, whereas no statistically significant difference was
observed between the other times. According to our findings,
the high BALP values at the third and sixth months of therapy
in the group receiving bortezomib can be interpreted as the
osteoblastic activity being increased in this group.
The results of our study are also in line with the clinical
findings of Shimazaki et al., who defined high BALP levels
following bortezomib combination therapy in resistant MM
[41]. In addition, it was reported that there was no significant
change in BALP levels in patients receiving dexamethasone,
whereas there was a significant increase in BALP levels in the
myeloma patients receiving bortezomib [39,42]. In the present
study, we determined a significant difference between the pretreatment
and post-treatment BALP values with bortezomib
therapy. On the other hand, the degree of improvement
obtained by chemotherapy not being in line with the healing
degree of the bone disease may be related to the increased
osteoclastic activity of MM even in the plateau period [21,22].
In the present study, the third and sixth month mean BALP
values being high in the no-treatment group may be explained
by decreased osteoclastic and increased osteoblastic activity,
because the majority of the patients in this group were in
remission (complete and/or almost complete). In some studies
concerning MM, it was determined that BALP levels were
associated with bone pain, lytic lesions, and bone fracture
[43]. From this point of view, achieving complete remission
and treating the bone disease appear to be important aims for
decreasing the morbidity and mortality of the patients.
In conclusion, the use of proteasome inhibitors such as
bortezomib, together with bisphosphonates, will no doubt
lead to much more positive outcomes in myeloma treatment.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
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Okano A, Okamoto M, Inaba T. High serum bone-specific
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380

Research Article
DOI: 10.4274/tjh.2013.0328
The Relationship of T Helper-2 Pathway Components
Interleukin-4, Interleukin-10, Immunoglobulin E, and
Eosinophils with Prognostic Markers in Non-Hodgkin
Lymphoma: A Case-Control Study
Yardımcı T Lenfosit-2 Yolağı Bileşenlerinden İnterlökin-4,
İnterlökin-10, İmmünglobülin E ve Eozinofiller’in Hodgkin-Dışı
Lenfoma’nın Prognostik Belirteçleri ile Olan İlişkisi-Kontrollü
Klinik Çalışma
Nil Güler 1 , Engin Kelkitli 1 , Hilmi Atay 1 , Dilek Erdem 2 , Hasan Alaçam 3 , Yüksel Bek 4 , Düzgün Özatlı 1 ,
Mehmet Turgut1, Levent Yıldız 5 , İdris Yücel 2
119 Mayıs University Faculty of Medicine, Department of Hematology, Samsun, Turkey
219 Mayıs University Faculty of Medicine, Department of Oncology, Samsun, Turkey
319 Mayıs University Faculty of Medicine, Department of Biochemistry, Samsun, Turkey
419 Mayıs University Faculty of Medicine, Department of Biostatistics, Samsun, Turkey
519 Mayıs University Faculty of Medicine, Department of Pathology, Samsun, Turkey
Abstract:
Objective: Increased risk for non-Hodgkin lymphoma (NHL) is associated with infections and environmental agents. We
hypothesized that these factors chronically trigger the T helper-2 (Th2) pathway and result in lymphoma. We investigated the
role of the Th2 pathway by exploring the relationships between components of the Th2 pathway, interleukin (IL)-10, IL-4,
immunoglobulin E (IgE), and eosinophils, and prognostic markers of NHL.
Materials and Methods: Thirty-one NHL patients and 27 healthy controls were enrolled. IL-10, IL-4, IgE, and eosinophils
were measured. IL-4 and IL-10 were analyzed with the enzyme amplified sensitivity immunoassay method.
Results: High IL-10 levels were correlated with several poor prognostic features, short early survival, and lymphopenia. There
was a positive correlation between albumin and IL-4 levels and a negative correlation between IL-10 and albumin. There was
no relationship related with eosinophils and IgE. We found remnant increased IL-4, which could be a clue for the triggering
of the Th2 pathway in the background.
Conclusion: There is a need for differently designed studies to detect the place of the Th2 pathway in NHL.
Key Words: Chemokines, Cytokines, Lymphocytes, Non-Hodgkin lymphoma, Th2 pathway
Address for Correspondence: Nil GÜLER, M.D.,
19 Mayıs University Faculty of Medicine, Department of Hematology, Samsun, Turkey
Phone: +362 312 19 19- 3521 E-mail: nilvecay@yahoo.com
Received/Geliş tarihi : September 25, 2013
Accepted/Kabul tarihi : November 18, 2013
381

Turk J Hematol 2014;31:381-387
Güler N, et al: The Place of T Helper-2 Pathway in NHL
Özet:
Amaç: Non-Hodgkin lenfoma (NHL) riski enfeksiyonlar ve çevresel ajanlarla artmış olarak ilişkilendirilmiştir. Hipotezimize
göre bu faktörlere kronik olarak maruz kalmak T helper-2 (Th2) yolağını aktifler ve lenfomaya sebep olur. Bu amaçla Th2 yolağı
komponentleri olan IL-10, IL-4, IgE, ve eozinofille, NHL’nin prognostik belirteçleri arasındaki ilişkiye baktık.
Gereç ve Yöntemler: Otuz bir NHL hastası ve 27 sağlıklı kontrolde IL-10, IL-4, IgE ve eozinofil değerlerine bakıldı. IL-4 ve
IL-10 EASIA metodu ile ölçüldü.
Bulgular: Yüksek IL-10 düzeyleri pek çok kötü prognostik özellikle, çok kısa yaşam süresi ve lenfopeni ile ilişkiliydi. Albümin
açısından IL-10 ile negatif ilişki, IL-4 ile pozitif ilişki bulundu. Eozinofil ve IgE ile ilgili herhangi bir ilişki kurulamadı. Bazı
hastalarda gözlenen artmış IL-4 geri planda kalmış Th2 yolağı aktivasyonunun bir ip ucu olabilir.
Sonuç: Th2 yolağının NHL patogenezindeki yerini tespit etmek için farklı dizaynlarda çalışmalara ihtiyaç vardır.
Anahtar Sözcükler: Kemokinler, Sitokinler, Lenfositler, Hodgkin dışı lenfoma, Th2 yolağı
Introduction
Increased risk for Non-Hodgkin lymphoma (NHL)
is associated with infections, environmental agents, and
immune suppression. The T helper-2 (Th2) immune reaction
is typically characterized by expression of interleukin (IL)-4,
IL-5, IL-9, IL-10, and IL-13; the recruitment of eosinophils,
basophils, and mast cells; and immunoglobulin (Ig) G-to-IgE
antibody class switching [1]. Exposure to an antigen may cause
an allergic reaction, but chronic exposure to the same allergen
at a low dose can cause immune tolerance via T regulatory
(T-reg) cell-associated Th2 suppression [2]. Anergy is defined
as the inability of antigen-specific cells to generate an allergic
reaction to an antigen [3].
IL-10 has a role in anergy as well as in immune suppression,
whereas IL-4 plays a predominant role in allergy [3]. IL-10
is produced mainly by Th2 cells, T-reg cells, monocytes, and
B lymphocytes and, in small amounts, by Th1 cells. IL-10
inhibits the proliferation of Th1 and Th2 cells in response to
specific antigens. IL-10 also inhibits the production of gammainterferon
(IFN-γ) and IL-2 by Th1 cells; the production of
IL-4 and IL-5 by Th2 cells; the production of IL-6, IL-8, IL-
12, TNF-α, and IL-1β by mononuclear phagocytes; and the
production of TNF-α and IFN-γ by natural killer cells. It
further inhibits monocytes [3,4,5]. Therefore, IL-10 is known
as a strongly inhibitory cytokine. IL-10 causes differentiation
of T-reg cells from T helper cells. T-reg cells secrete IL-10,
IFN-γ, TGF-β, and IL-5 [3]. T-reg cells also suppress functions
of Th1 and Th2 cells [6]. Secretion of IL-4 by the Th2 pathway
induces allergy. Desensitization treatments can be done if an
allergic patient is chronically treated with a related allergen at
a low dose. Allergic individuals develop anergy via IL-10.
We hypothesized that chronic stimulation by environmental
agents triggers the Th2 pathway and anergy. The Th2 pathway
is shifted from IL-4 to IL-10 in anergy. It is well known that
high IL-10 triggers the differentiation of T-reg cells from T
helper cells. Once T-reg cells are increased, these cells will
start to inhibit functions of Th2 and Th1 cells and start to
secrete their own IL-10. In addition, if high levels of IL-10
persist, it causes serious immune suppression. Therefore, we
examined the relationships between prognostic markers in
NHL and components of the Th2 pathway, such as IL-10, IL-
4, IgE, and eosinophils. Figure 1 illustrates our hypothesis.
Materials and Methods
Thirty-one newly diagnosed NHL patients and 27 healthy
controls were enrolled. The median ages of patients and
controls were 64 (range: 19-85) and 26 (range: 23-60) years,
respectively. All participants were free of history of allergy,
dermatitis, or parasites in stool samples, because allergies
and parasites can trigger the Th2 pathway and could cause
misleading results.
Twenty-seven patients had diffuse large B cell lymphoma
(DLBCL) and 4 patients had T-cell lymphoma. The
characteristics of the patients are given in Table 1.
Initial blood samples were collected to test IL-4, IL-10,
and IgE levels. Patient pretreatment values for eosinophils,
hemoglobin, lymphocytes, lactate dehydrogenase (LDH),
C-reactive protein (CRP), sedimentation, b2 microglobulin,
and albumin were collected from the patient records. A second
blood sample for IL-4 and IL-10 was collected from only the
patients after completion of the 4 cycles of chemotherapy. The
chemotherapy regimens were decided by their physicians. The
blood samples for IL-10 and IL-4 were collected into tubes
with no anticoagulant. The samples were centrifuged within
2 h at 4000 rpm for 10 min, and the serum was separated and
kept at -80 °C.
The IL-4 and IL-10 concentrations were analyzed from
serum samples using the enzyme amplified sensitivity
immunoassay (EASIA) method in accordance with
the instructions of the kit’s manufacturer (DIAsource
ImmunoAssays, Cat. No. KAP1281 and KAP1321, Belgium).
382

Güler N, et al: The Place of T Helper-2 Pathway in NHL
Turk J Hematol 2014;31:381-387
These IL-4 and IL-10 assays are specific for endogenous
human IL-4 and IL-10, respectively. The samples were
processed in duplicate. The detection limits of the kits for
IL-4 and IL-10 are 1.2 pg/mL and 1.6 pg/mL, respectively. The
intraassay and interassay variation of the IL-4 kit was 3.8%
and 4.5%, respectively. The intraassay and interassay variation
of the IL-10 kit was 2.8% and 2.8%, respectively. The results
are presented in pg/mL.
The Eastern Cooperative Oncology Group (ECOG)
performance status system and the Ann Arbor staging system
were used. International Prognostic Index (IPI) scores were
categorized as low risk (scores 0-2) or high risk (scores 3-5).
T-cell lymphoma patients were treated with CHOP
(cyclophosphamide, doxorubicin, vincristine, and prednisone)
chemotherapy. DLBCL patients were treated with rituximab
plus CHOP.
Overall survival (OS) was determined as the time between
the diagnosis of lymphoma and the last evaluation in the
hospital or death for any reason during the study.
The university’s local ethics committee approved this
study and all participants gave informed consent. This study
is in accordance with the Helsinki Declaration of 1975.
Statistical Analysis
Statistical analyses were performed using SPSS 15.0.
The normality of distribution was checked by Kolmogorov-
Smirnov test. For variables not confirming to normal
distribution comparisons were analyzed with the Mann-
Whitney U-test. The Wilcoxon signed-rank test, Kruskal-
Wallis test, Spearman test, Pearson chi-square test, and Fisher
exact test were also used. Statistical significance was accepted
at p8.24 and
IL-4 of >43.05 (4 patients); group 4, IL-10 of >8.24 and IL-4 of
≤43.05 (11 patients). Because it only included a single patient,
group 1 was not evaluated. We did not observe a significant
difference between groups 2 and 3 with respect to albumin
(p=0.548), while there was a difference between groups 2
and 4 (p=0.005) and between groups 3 and 4 (p=0.026). The
significant difference between groups 3 and 4 was noteworthy
because both of these groups consisted of patients with high
IL-10. However, IL-4 was higher in group 3 and lower in group
4. The highest albumin values were observed in group 3. As
mentioned above, there was a negative correlation between IL-
10 levels and albumin in the entire patient sample (r=-0.46,
p=0.01). Despite the high IL-10 level, albumin levels were
high in group 3.
The lack of a difference between group 2 and group 3 was
also important. IL-10 levels were low in group 2. The albumin
values in group 3 did not differ from those of group 2 despite
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Güler N, et al: The Place of T Helper-2 Pathway in NHL
high IL-10 levels. These results suggest that IL-4 alleviates or
restores the repressive effects of IL-10 on albumin (Figure 2).
Seven of 15 patients with high IL-10 (46%) and 4 of 16
patients with low IL-10 (25%) died during the follow-up for a
total number of 11 deceased patients. Ten of these 11 patients
died before the completion of the fourth cycle of chemotherapy.
Our mean observation period was 281.44 days (range: 19-
402). The minimum observation time in living patients was
112 days. Therefore, we relied on short-time surveying.
The highest IL-10 value in living patients was 107.1 pg/
mL, 13-fold higher than the cut-off value. This value was
found in patient number 21. This patient also exhibited a very
high IL-4 value of 2081 pg/mL, 48-fold higher than the cut-off
value.
Figure 1. Presentation of the hypothesis. Dashed arrows
indicate suppressive effect.
Figure 2. Mean albumin values (g/dL) after removal of group
1 (with 1 patient only) from analysis.
Table 1. The characteristics of the patients.
Characteristics Variables n %
Lymphoma type DLBCL 27 87
T-cell lymphoma 4 13
Age ≤60 13 42
>60 18 58
ECOG

Güler N, et al: The Place of T Helper-2 Pathway in NHL
Turk J Hematol 2014;31:381-387
For survival analysis, the patients were classified into 3
groups according to the cut-off value (8.24 pg/mL) and the
highest value (107 pg/mL) in living patients: Group A, IL-10 of
≤8.24 (16 patients); group B, 8.24 < IL-10 ≤107 (11 patients);
and group C, IL-10 of >107 (4 patients). The Kaplan-Meier test
and log rank analysis were performed for the survival analysis.
The mean survival times were 323 days in group A, 285
days in group B, and 38.7 days in group C. The differences
were statistically significant (p=08.24; 15 patients). Lymphocyte counts were
decreased in the latter group (p=0.002).
Differences in the relationships between IL-4 and age, CRP,
hemoglobin, extranodal involvement, ECOG performance,
stage, lymphopenia, LDH, lymphoid tissue size, IPI score, ≥2
microglobulin, or B symptoms were not observed.
The characteristics of patients with T-cell lymphoma are
shown in Table 2.
Discussion
In this study, high IL-10 levels were correlated with several
poor prognostic features, including low albumin. However,
IL-4 was positively correlated with albumin. In addition, IL-4
was able to overcome the negative effects of IL-10 on albumin.
To our knowledge, this is the first study to detect a positive
relationship between IL-4 and albumin and the ability of IL-4
to overcome the effects of IL-10 on albumin in NHL patients.
IL-4 is an agent used in experimental treatment for
NHL. The rationalization for this treatment is based on the
observation of the inhibitory effect of IL-4 on NHL B cells and
cancer cells in vitro [7,8].
In the literature, IL-10 is generally connected to the poor
prognostic factors of NHL. One of the most noteworthy
relevant studies was performed by Blay et al. They observed
detectable IL-10 levels in 46% of patients with active disease.
Detectable IL-10 levels were related to very short survival [9].
However, Cortes et al. could not observe a relationship with
complete remission, failure-free survival, or OS. There was
also no relationship between IL-10 and any prognostic factors
except B symptoms [10].
Lech-Maranda et al. observed a relationship between
detectable IL-10 levels and age of >60, ECOG status of ≥2,
Table 2. The characteristic of patients with T-cell lymphoma.
Patient
number
Type
IL-10,
pg/mL
IL-4,
pg/mL
Lymphocytes,
x10 9 /L
IgE
Eosinophil
count,
x10 9 /L
Exitus Follow-up
(days)
Albumin
27 PTCL 45.76 ↑ 69.56 ↑ 0.89↓ 239↑ N Ex 66 N
29 PTCL 687.2 ↑↑ 19.04 N 0.2↓ N N Ex 19 ↓
30 PTCL 6.65 N 20.91 N 2.06 N N Ex 94 N
31 AITL 43.06↑ 19.418 N 2.00 164↑ 8.0 ↑↑ 275 ↓
PTCL: peripheral T-cell lymphoma, AITL: angioimmunoblastic T-cell lymphoma, ↓: low, N: normal, ↑: high, ↑↑: very high. The cut-off values used were 8.24 pg/mL and
43.05 pg/mL for IL-10 and IL-4, respectively.
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Güler N, et al: The Place of T Helper-2 Pathway in NHL
advanced stage, bulky tumor mass, high LDH, high IPI score,
≥2 microglobulin, anemia, existence of B symptoms, low
albumin, low CR rate, and shorter progression-free survival
and OS [11]. Nacinovic-Duletic et al. reported similar
results. The patients with high IL-10 exhibited shorter
survival [12]. However, Guney et al. observed only the
relationship between IL-10 and high LDH and bone marrow
involvement [13]. They detected significant decreases in IL-
10 levels after chemotherapy. Fabre-Guillevin et al. did not
find any relationship between IL-4 or IL-10 and complete
remission, failure-free survival, or OS [14].
As mentioned before, Lech-Maranda et al. observed a
negative correlation between albumin and IL-10 [11]. Our
finding was consistent with this result; in addition, we
observed a positive effect of IL-4 on albumin.
Lymphopenia is related to poor prognosis in many cancers
[15,16]. In our study, the pretreatment lymphocyte count
was negatively correlated with IL-10. To our knowledge,
this is the first study in which lymphopenia was found to be
related to high IL-10 levels in NHL. Some researchers have
observed this relationship in sepsis [17,18].
We cannot define the source of high IL-10 levels in our
study; it could be Th2, T-reg, or tumor cells. According to
our hypothesis, NHL pathogenesis starts with Th2 pathway
activation. We know that the increased secretion of IL-10 by
Th2 cells can promote the development of T-reg cells from T
helper cells, and newly developed T-reg cells begin to secrete
their own IL-10 and inhibit both Th1 and Th2 functions [3,6].
As mentioned above, IL-10 is a strong inhibitor cytokine. In
situations of very highly increased IL-10 levels, the inhibitor
effect of IL-10 will be particularly enormous and will result
in strong inhibition of Th1 and Th2 cell function. With the
suppressive effect of IL-10, Th2 cannot produce IL-4. Our
interpretation of the increase in IL-4 that was observed in
some patients (5 patients with increased pretreatment IL-4
and 3 with increased posttreatment IL-4 values) is that
there may be remnant Th2 pathway activation, which could
have escaped the suppressive effect of IL-10. It is hard to
show the initial activity of Th2 cells at the time of disease
development because we are most likely catching patients
after the switching of Th2 cell activity to increased T-reg cell
activity and at a point when the disease is well established.
To our knowledge, this is the first study to investigate the
place of the Th2 pathway in NHL through the components
of Th2 by detection of IgE, eosinophils, IL-10, and IL-4.
IL-10 was related to very early death in this study.
Therefore, we think that other treatment options may be
more effective for patients with very high IL-10, such as anti-
IL-10 antibody in addition to CHOP. However, one could
also make a different comment: if an increasing IL-10 level is
accompanying NHL, the increased IL-10 may be a reaction
of the immune system, and supporting this reaction may
help to control the aggression of lymphoma.
Acknowledgment
Special thanks to Timuçin Güler for interpretation of our
results.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/
or affiliations relevant to the subject matter or materials
included.
Authorship Contributions:
Nil Güler: Proposed the hypothesis, designed the research, collected
data, performed research, analyzed and interpreted data, wrote the
manuscript.
Engin Kelkitli: Collected data, performed research.
Hilmi Atay: Collected data, performed research.
Dilek Erdem: Collected data, performed research.
Hasan Alaçam: Performed research, analyzed and interpreted data.
Yüksel Bek: Performed statistical analysis, analyzed and interpreted
data.
Düzgün Özatlı: Collected data, performed research.
Mehmet Turgut: Collected data, performed research.
Levent Yıldız: Performed research.
İdris Yücel: Collected data, analyzed and interpreted data.
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387

Research Article
DOI: 10.4274/tjh.2013.0098
The Association of HLA Class 1 and Class 2 Antigens
with Multiple Myeloma in Iranian Patients
İranlı Multipl Miyelom Hastalarında HLA Sınıf 1 ve Sınıf 2
Antijenlerinin Birlikteliği
Arezou Sayad 1 , Mohammad Taghi Akbari 2 , Mahshid Mehdizadeh 3,4 , Elham Roshandel 3 ,
Soheila Abedinpour 3 , Abbas Hajifathali 3
1Shahid Beheshti University of Medical Sciences, Department of Medical Genetics, Tehran, Iran
2Tarbiat Modares University Faculty of Medical Science, Department of Medical Genetics, Tehran, Iran
3Shahid Beheshti University of Medical Sciences, Taleghani Bone Marrow Transplantation Center, Tehran, Iran
4Shahid Beheshti University of Medical Sciences, Pediatric Congenital Hematologic Disorders Research Center, Tehran, Iran
Abstract:
Objective: Multiple myeloma (MM) is a B-cell malignancy characterized by the clonal proliferation of malignant plasma cells.
According to results of some studies, it has been suggested that the HLA class 1 and 2 genes have susceptibility effects on MM.
Studies of different populations have reported different HLA class 1 and 2 alleles that affect MM. In this study, we assessed
the association of HLA class 1 and class 2 antigens with MM in Iranian patients.
Materials and Methods: We performed a case-control genotyping study with 105 Iranian MM patients that were selected
from the bone marrow transplantation department of Taleghani Hospital and 150 controls using single specific primerpolymerase
chain reaction with the HLA-Ready Gene ABDR Kit.
Results: Our results demonstrated that 21% of patients versus 12% of controls and 11% of patients versus 3% of controls
carried HLA-A*03 and HLA-B*18, respectively. The MM patients had a significant increase in the frequency of HLA-A*03 and
HLA-B*18 alleles in comparison to control subjects (p=0.039, OR=2.057 and p=0.013, OR=3.567, respectively).
Conclusion: Our findings suggested that the HLA-A*03 and HLA-B*18 alleles have significant susceptibility effects on MM
in the Iranian population. However, compared to other populations, the above-mentioned alleles had different statuses. Since
there are not many studies evaluating and calculating this association among ethnic groups, further studies among other
populations are needed to explain the exact association of the HLA genes with MM.
Key Words: Multiple myeloma, HLA-A, HLA-B, HLA-DRB1, Genetic susceptibility
Özet:
Amaç: Multiple myeloma (MM), malign plazma hürelerinin klonal çoğalması ile karakterize bir B hücre neoplazisidir. Çeşitli
çalışmaların sonuçlarına göre, bazı sınıf 1 ve 2 HLA genlerinin hastalığa yatkınlık sağladığına dair görüşler ortaya atılmıştır.
Address for Correspondence: Abbas HAJIFATHALI, M.D.,
Shahid Beheshti University of Medical Sciences, Taleghani Bone Marrow Transplantation Center, Tehran, Iran
E-mail: ar.sayad@yahoo.com
Received/Geliş tarihi : March 17, 2013
Accepted/Kabul tarihi : June 10, 2013
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Sayad A, et al: Association of HLA with Multiple Myeloma
Turk J Hematol 2014;31:388-393
Farklı popülasyonlarda yapılan çalışmalarda, farklı HLA sınıf 1 ve 2 allellerinin MM üzerine etkisi olduğu bildirilmiştir. Bu
çalışmada, İranlı MM hastalarında HLA sınıf 1 ve sınıf 2 antijenlerinin birlikteliğini değerlendirdik.
Gereç ve Yöntemler: HLA-Ready Gene ABDR kitleriyle tekli spesifik primer polimeraz zincir reaksiyonu yönteminin
kullanıldığı bu olgu-kontrol genetiplendirme çalışmasında, hasta grubuna Taleghani Hastanesi kemik iliği nakli bölümünden
seçilen 105 İranlı MM hastası ve 150 de kontrol olgusu dahil edilmiştir.
Bulgular: Çalışma sonucunda, HLA-A*03 hasta grubunda %21 ve kontrol grubunda %12 bulunurken, HLA-B*18 ise hasta
grubunda %11 ve kontrol grubunda %3 olarak saptanmıştır. MM hastalarının HLA-A*03 ve HLA-B*18 allele sahip olma oranı
kontrol olgularıyla karşılaştırıldığında istatistiki olarak anlamlı olacak şekilde yüksek bulunmuştur (p=0,039, OR=2,057 ve
p=0,013, OR=3,567, sırasıyla).
Sonuç: Bizim bulgularımız, İran toplumunda HLA-A*03 ve HLA-B*18 allel varlığının istatistiki olarak anlamlı olacak şekilde
MM’ye yatkınlık yarattığını ortaya koymaktadır. Bununla birlikte, diğer toplumlara bakıldığında adı geçen allellerin aynı sonucu
doğurmadıkları görülmektedir. Farklı etnik gruplar arasındaki bu birlikteliği değerlendiren fazla sayıda çalışma olmadığı için,
gelecek dönemlerde MM’li hastalarda HLA genlerinin birlikteliğinin sonuçlarını izah edebilecek daha ayrıntılı çalışmalara
gereksinim vardır.
Anahtar Sözcükler: Multipl miyelom, HLA-A, HLA-B, HLA-DRB1, Genetik yatkınlık
Introduction
Multiple myeloma (MM) is a B-cell malignancy
characterized by the clonal proliferation of malignant
plasma cells, and evidence indicates that the bone marrow
microenvironments of tumor cells have a crucial role in
myeloma pathogenesis [1]. Neurological and impaired
hemopoiesis symptoms, bone complications, renal failure,
and infection are some of the heterogeneous clinical features
[2]. MM is the second most prevalent blood cancer after non-
Hodgkin lymphoma [3]. MM represents approximately 1% of
all cancers, 2% of all cancer deaths, and 10% of hematological
malignancies. The prevalence of MM varies among different
populations. Blacks have a 2-fold higher incidence than
whites, while the Japanese, Chinese, and South Koreans
have the lowest incidence [4,5]. Although the exact etiology
of MM is unknown, the genetic factor has an important
effect on it. Simply, MM is a condition characterized by the
unlimited proliferation of plasma cells. Since the HLA genes
are associated with a variety of immunologic diseases, they
may be involved as a crucial factor in MM [6]. In 1970 for
the first time, after recognition of HLA class 1 and prior to
identification of HLA class 2, the susceptibility effects of
HLA genes on MM were studied [7,8,9,10,11,12]. Not many
studies have taken sufficient account of the effect of HLA
genes on the susceptibility to MM in different populations.
These studies reported different susceptible or protective
alleles of HLA genes in association with MM. Some studies
indicated no significant association between HLA-A and
-B genes and MM, while other studies demonstrated that
HLA-A3, -B18, -Bw65, and -DRw14 had associations with
MM [13,14,15]. In the present study, for the first time, the
associations of HLA class 1 and 2 genes with MM in Iranian
patients were investigated.
Materials and Methods
Patients and Controls
One hundred and five Iranian patients were selected from
the bone marrow transplantation department of Taleghani
Hospital. The diagnosis of MM was made by an oncologist.
Additionally, one hundred and twenty ethnically, age-, and
sex-matched healthy individuals without personal or familial
history of cancer or autoimmune disorders were included as
controls. The subjects gave informed consent to participate.
DNA Extraction and HLA Genotyping
Genomic DNA from venous peripheral blood samples was
extracted by the salting-out method [16]. HLA typing was
performed at the Tehran Medical Genetics Laboratory. HLA-A,
-B, and -DRB1 genotyping was carried out based on lowresolution
single specific primer-polymerase chain reaction
(SSP-PCR) HLA typing with the HLA-Ready Gene ABDR Kit
(Inno-Train Diagnostik GmbH, Germany) according to the
manufacturer’s recommendation. The PCR products were run
on 2% agarose gel.
Statistical Analysis
By using chi-square and Fisher exact tests, comparisons
between HLA-A, -B, and -DRB1 alleles of MM patients and
the controls were performed. SPSS 18.0 for Windows was
used for analysis and p

Turk J Hematol 2014;31:388-393
Sayad A, et al: Association of HLA with Multiple Myeloma
-DRB1 in MM patients and controls are demonstrated in Table
2. As outlined in Table 2, no significant associations between
HLA-DRB1 and MM were observed. Low-resolution HLA
typing revealed that 21% of patients versus 12% of controls
and 11% of patients versus 3% of controls carried HLA-A*03
and HLA-B*18, respectively. The MM group had a significant
increase in the frequency of HLA-A*03 and HLA-B*18 alleles
in comparison to control subjects (p=0.039, OR=2.057 and
p=0.013, OR=3.567, respectively) (Table 2).
Discussion
After description of a serological technique for HLA typing,
studies on the association of the HLA genes with susceptibility
to or protection against different disease were begun. In our
research, for the first time, we investigated the association of
HLA class 1 and 2 genes with MM disease in Iranian patients.
In our study, the HLA-A*03 and HLA-B*18 alleles had higher
frequencies in MM patients than in control individuals and
had significantly positive associations with MM. Therefore, the
HLA-A*03 and HLA-B*18 alleles have a susceptibility effect in
Iranian MM patients (p=0.039 and OR=2.057, p=0.013 and
OR=3.567, respectively).
Consistent with our results, in 2002, a study on 68 MM
patients in southern Africa reported that the HLA-B*18 allele
had an association (p

Sayad A, et al: Association of HLA with Multiple Myeloma
Turk J Hematol 2014;31:388-393
Table 2. The allele frequencies of HLA-A, -B, and -DRB1 in multiple myelom (MM) patient and control groups.
Alleles
MM patients, Controls, p-value a pc-value b OR (95% CI)
n=210 [no. (%)] n=300
[no. (%)]
HLA-A*01 19 (9) 26 (9) 0.881 NS 1.048 (0.564-1.948)
HLA-A*02 48 (23) 53 (27) 0.148 NS 1.381 (0.891-2.140)
HLA-A*03 46 (21) 36 (12) 0.003 0.039 2.057 (1.276-3.316)
HLA-A*11 17 (8) 27 (10) 0.72 NS 0.891 (0.472-1.679)
HLA-A*23 8 (4) 10 (3) 0.032 NS 3.921 (1.028-14.957)
HLA-A*24 38 (18) 40 (18) 0.141 NS 1.436 (0.885-2.330)
HLA-A*26 8 (4) 14 (5) 0.131 NS 2.337 (0.754-7.245)
HLA-A*29 4 (2) 2 (1) 0.235 c NS 2.893 (0.525-15.943)
HLA-A*30 4 (2) 10 (3) 0.454 c NS 1.922 (0.426-8.680)
HLA-A*31 13 (6) 12 (5) 0.259 NS 1.584 (0.708-3.543)
HLA-A*32 1 (1) 10(3) 0.647 c NS 0.474 (0.049-4.585)
HLA-A*33 2 (1) 5 (2) 0.705 c NS 0.567 (0.109-2.952)
HLA-A*68 2 (1) 5 (2) 0.705 c NS 0.567 (0.109-2.952)
HLA-B*07 11 (5) 18 (6) 0.715 NS 0.866 (0.400-1.874)
HLA-B*08 5 (2) 10 (3) 0.283 c NS 2.415 (0.571-10.216)
HLA-B*09 2 (1) 2 (1) 1.000 c NS 1.433 (0.200-10.252)
HLA-B*13 4 (2) 12 (4) 0.182 NS 0.466 (0.148-1.465)
HLA-B*14 0 (0) 3 (1) 0.272 NS -
HLA-B*15 2 (1) 3 (1) 1.000 c NS 0.952 (0.158-5.747)
HLA-B*18 23 (11) 10 (3) 0.001 0.013 3.567 (1.660-7.664)
HLA-B*27 6 (3) 10 (3) 0.761 NS 0.853 (0.305-2.384)
HLA-B*35 52 (25) 84 (28) 0.416 NS 0.846 (0.566-1.265)
HLA-B*37 0 (0) 3 (1) 0.272 c NS 1.707 (1.587-1.837)
HLA-B*38 17 (8) 18 (6) 0.357 NS 1.380 (0.694-2.745)
HLA-B*39 6 (3) 4 (1) 0.222 NS 2.176 (0.607-7.810)
HLA-B*40 6 (3) 6 (2) 0.530 NS 1.441 (0.458-4.531)
HLA-B*41 2 (1) 2 (1) 1.000 c NS 1.433 (0.200-10.252)
HLA-B*44 17 (8) 21 (7) 0.643 NS 1.170 (0.602-2.276)
HLA-B*48 2 (1) 3 (1) 1.000 c NS 0.952 (0.158-5.747)
HLA-B*49 5 (2) 6 (2) 0.771 NS 1.195 (0.360-3.969)
`HLA-B*50 2 (1) 7 (2) 0.244 NS 0.402 (0.083-1.957)
HLA-B*51 (14) 51 (17) 0.330 NS 0.782 (0.477-1.283)
HLA-B*52 6 (3) 7 (2) 0.712 NS 1.231 (0.408-3.717)
HLA-B*53 0 (0) 2 (1) 0.515 NS -
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Turk J Hematol 2014;31:388-393
Sayad A, et al: Association of HLA with Multiple Myeloma
HLA-B*54 0 (0) 3 (1) 0.272 NS -
HLA-B*55 0 (0) 2 (1) 0.515 NS -
HLA-B*56 0 (0) 3 (1) 0.272 NS -
HLA-B*57 5 (2) 5 (2) 0.567 NS 1.439 (0.411-5.034)
HLA-B*58 8 (4) 5 (2) 0.131 NS 2.337 (0.754-7.245)
HLA-DRB1*01 6 (3) 15 (5) 0.231 NS 0.559 (0.213-1.465)
HLA-DRB1*03 29 (14) 30 (10) 0.186 NS 1.442 (0.837-2.484)
HLA-DRB1*04 15 (7) 24 (8) 0.720 NS 0.885 (0.452-1.730)
HLA-DRB1*07 8 (4) 12 (4) 0.913 NS 0.950 (0.382-2.367)
HLA-DRB1*08 1 (1) 3 (1) 0.647 c NS 0.474 (0.049-4.585)
HLA-DRB1*09 5 (2) 3 (1) 0.217 c NS 2.415 (0.571-10.216)
HLA-DRB1*10 11 (5) 12 (4) 0.507 NS 1.327 (0.574-3.066)
HLA-DRB1*11 80 (38) 126 (42) 0.376 NS 0.850 (0.592-1.219)
HLA-DRB1*12 5 (2) 2 (1) 0.130 NS 3.634 (0.698-18.912)
HLA-DRB1*13 19 (9) 30 (10) 0.719 NS 0.895 (0.489-1.638)
HLA-DRB1*14 20 (10) 21 (7) 0.302 NS 1.398 (0.738-2.651)
HLA-DRB1*15 5 (2) 12 (4) 0.316 NS 0.585 (0.203-1.687)
HLA-DRB1*16 6 (3) 10 (3) 0.761 NS 0.853 (0.305-2.384)
a: Value of chi-square or Fisher exact test prior to Bonferroni correction. b: Value of chi-square or Fisher exact test with Bonferroni correction. c: Tested with Fisher exact
test. n: number of alleles. NS: not significant.
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incidence in metropolitan Atlanta, Georgia: racial and seasonal
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6. Cassuto JP, Piereschi J, Maiolini R, Dujardin P, Ribeil R,
Masseyeff R. Marqueurs HLA dans les myélomes et les
dysglobulinémies monoclonales bénignes. Nouv Presse Med
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393

Research Article
DOI: 10.4274/tjh.2012.0154
New Insights on Iron Study in Myelodysplasia
Miyelodisplazide Demir Testleri ile İlgili Yeni Görüşler
Noha M. El Husseiny 1 , Dina Ahmed Mehaney 2 , Mohamed Abd El Kader Morad 1
1Cairo University Faculty of Medicine, Department of Clinical Hematology, Cairo, Egypt
2Cairo University Faculty of Medicine, Department of Chemical Pathology, Cairo, Egypt
Abstract:
Objective: Hepcidin plays a pivotal role in iron homeostasis. It is predominantly produced by hepatocytes and inhibits iron
release from macrophages and iron uptake by intestinal epithelial cells. Competitive ELISA is the current method of choice
for the quantification of serum hepcidin because of its lower detection limit, low costs, and high throughput. This study aims
to discuss the role of hepcidin in the pathogenesis of iron overload in recently diagnosed myelodysplasia (MDS) cases.
Materials and Methods: The study included 21 recently diagnosed MDS patients and 13 healthy controls. Ferritin,
hepcidin, and soluble transferrin receptor (sTFR) were measured in all subjects.
Results: There were 7 cases of hypocellular MDS, 8 cases of refractory cytopenia with multilineage dysplasia, and 6 cases
of refractory anemia with excess blasts. No difference was observed among the 3 MDS subtypes in terms of hepcidin, sTFR,
and ferritin levels (p>0.05). Mean hepcidin levels in the MDS and control groups were 55.8±21.5 ng/mL and 19.9±2.6 ng/
mL, respectively. Mean sTFR was 45.7±8.8 nmol/L in MDS patients and 31.1±5.6 nmol/L in the controls. Mean ferritin levels
were significantly higher in MDS patients than in controls (539.14±83.5 ng/mL vs. 104.6±42.9 ng/mL, p0.05).
Conclusion: Hepcidin may not be the main cause of iron overload in MDS. Further studies are required to test failure of
production or peripheral unresponsiveness to hepcidin in MDS cases.
Key Words: Hepcidin, Myelodysplasia, Iron overload
Özet:
Amaç: Hepsidin demir dengesinde önemli bir rol oynar. Temel olarak hepatositler tarafından üretilir ve intestinal epitel
hücrelerinden demir alımını ve makrofajlardan demir salınımını inhibe eder. Kompetitif ELİZA en düşük düzeyleri
saptayabilmesi, düşük maliyeti ve yüksek test kapasitesi ile kantitatif serum hepsidin miktari ölçümü için tercih edilen
mevcut bir yöntemdir. Bu çalışmanın amacı son zamanlarda miyelodisplazi (MDS) tanısı almış olgularda demir yükünün
patogenezinde hepsidinin rolünü tartışmaktır.
Address for Correspondence: Noha M. EL HUSSEINY, M.D.,
Cairo University Faculty of Medicine, Department of Clinical Hematology, Cairo, Egypt
E-mail: dr_noha2002@yahoo.com
Received/Geliş tarihi : October 16, 2012
Accepted/Kabul tarihi : January 21, 2013
394

El Husseiny MN, et al: Iron Status in Myelodysplasia
Turk J Hematol 2014;31:394-398
Gereç ve Yöntemler: Bu çalışmaya 21 yeni tanı MDS hastası ve 13 sağlıklı kontrol alındı. Ferritin, hepsidin ve soluble
transferrin reseptörü (sTFR) tüm olgularda ölçüldü.
Bulgular: Hiposellüler MDS’li 7 olgu, multilineage displazili refrakter sitopenili 8 olgu ve artmış blastlı refrakter anemili 6 olgu
vardı. Bu 3 MDS alt tipleri arasında hepsidin, sTFR ve ferritin düzeyleri açısından fark gözlenmedi (p>0,05). Ortalama hepsidin
seviyesi sırasıyla MDS grubunda 55,8±21,5 ng/mL ve kontrol grubunda ise 19,9±2,6 ng/mL idi. Ortalama sTFR, MDS grubunda
45,7±8,8 nmol/L ve kontrol grubunda ise 31,1±5,6 nmol/L idi. Ortalama ferritin seviyeleri ise MDS grubunda kontrolden anlamlı
olarak yüksekti (539,14±83,5 ng/mL vs. 104,6±42,9 ng/mL, p0,05).
Sonuç: Hepsidin MDS’de aşırı demir yükünün ana nedeni olmayabilir. MDS’li olgularda hepsidine çevresel yanıtsızlık veya
üretimi yetersizliğini test edecek başka çalışmalara ihtiyaç vardır.
Anahtar Sözcükler: Hepsidin, Miyelodisplazi, Demir yükü
Introduction
Myelodysplastic syndrome (MDS) is a group of
clonal hemopoietic disorders characterized by ineffective
hematopoiesis, bone marrow dysplasia, and an increased risk of
transformation to acute myeloid leukemia. The large majority
of patients with MDS are anemic and eventually up to 90% of
them require regular transfusions. In 50% to 60% of patients,
anemia is severe, with hemoglobin levels below 10 g/dL [1].
The liver polypeptide hepcidin plays a pivotal role in iron
homeostasis. In macrophages, it accelerates the degradation
of the trans-membrane iron exporter ferroportin mRNA.
In intestinal epithelial cells, it is believed to down-regulate
divalent metal transporter-1, which is involved in the transfer
of iron across the intestinal wall [2].
Previous reports on hepcidin levels in MDS showed
conflicting results. Murphy et al. found that urinary excretion
of hepcidin was lower in MDS in comparison to the control
group and interpreted this finding as evidence for hepcidin’s
role in iron overload in MDS [3]. However, others reported
contrary findings [4]. In an earlier study, we measured prohepcidin
in MDS and found it to be significantly lower in
comparison to levels in the control group [5]. However, the
utility of the prohepcidin assay is controversial [6].
The development of quantification techniques based
on mass spectrometry [matrix-assisted laser desorption
ionization, surface enhanced laser desorption/ionization
time-of-flight mass spectrometry (SELDI-TOF MS), or liquid
chromatography tandem mass spectrometry] has shown
promising results. However, some of these approaches did
not use internal standards for the quantification of hepcidin
and are considered semi-quantitative; moreover they require
specialized equipment that is not widely accessible [7].
Regarding MDS, there are only a few conflicting data about
urinary hepcidin measured by using first generation semiquantitative
techniques [8]. The competitive enzyme-linked
immunosorbent assay (ELISA) is currently the method of
choice for the quantification of serum hepcidin because of its
lower detection limit, low costs, and high throughput [6].
Although prolonged red blood cell transfusion therapy
appears to be the main contributor to iron overload in MDS,
many patients appear to develop iron overload at an early
stage of the disease, before the onset of transfusions. It has
been postulated that an altered production of hepcidin, the
recently discovered key hormone regulating iron homeostasis,
may play a role in this regard [8].
The aim of this study was to find out whether hepcidin
plays a key role in the pathogenesis of iron overload seen
in recently diagnosed MDS, or whether hepcidin levels are
just a consequence of the interaction between ineffective
erythropoiesis and blood transfusion.
Materials and Methods
This study included 21 MDS patients recently diagnosed in
the Clinical Hematology Unit of Cairo University. All patients
who had an MDS diagnosis of less than 6 months entered the
study if they were not on iron chelation, had no evidence of
infection and no renal or liver impairment, and did not receive
more than 10 units of blood. Ethical committee approval of
the study was obtained. Each individual in the study signed a
consent form.
Five milliliters of venous blood was obtained from each
individual in the study after at least 8 h of fasting. For MDS
patients, samples were taken at least 5 days after the last
transfusion to avoid acute alterations in the hepcidin level.
The samples were centrifuged at 3000 rpm for 10 min to
separate sera and stored at -80 °C until analyzed.
Serum levels of hepcidin were determined using a
commercially available ELISA kit (DRG Instruments GmbH,
Marburg, Germany) according to the manufacturer’s protocol.
The 5% to 95% range in apparently normal, healthy adults is
between 13.3 and 54.4 ng/mL.
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Turk J Hematol 2014;31:394-398
El Husseiny MN, et al: Iron Status in Myelodysplasia
Soluble transferrin receptor (sTFR) concentrations
were measured in serum, stored at -80 °C, with the use of
a commercially available ELISA kit (Quantikine IVD Soluble
Transferrin Receptor ELISA; R&D Systems Europe Ltd.,
Abingdon, UK). The reference interval is 8.7-28.1 nmol/L.
Serum ferritin was quantified using the DRG ferritin kit
(ELISA) kit (EIA-1872; DRG International Inc., Mountainside,
NJ, USA). The reference interval in healthy males and females
is 20-250 ng/mL and 10-120 ng/mL, respectively.
Statistics Analysis
SPSS 17 was used for descriptive analysis and comparisons.
Spearman’s test was used for correlation analysis and
analysis of variance (ANOVA) was used for the comparison
of multiple parameters among different groups. Differences
and correlations were considered significant when p0.05, Table
3). Mean hepcidin/ferritin ratio in patients with MDS was
higher than in the controls (0.48±1.2 vs. 0.32±0.19), but this
was not statistically significant (p=0.6).
Discussion
It has been reported that ineffective erythropoiesis
enhances iron absorption in MDS through down-regulation
of hepcidin and its prohormone such that serum ferritin rises
to 500-600 ng/mL but seldom exceeds these values before
Table 1. Iron parameters.
Parameter Patients Healthy p
with MDS controls
Hepcidin
(ng/mL, mean±SD)
55.8±21.5 19.9±2.6 0.06
Ferritin
(ng/mL, mean±SD)
sTFR
(nmol/L, mean±SD)
539.14±83.5 104.6±42.9 0.005
45.7±8.8 31.1±5.6 0.6
DS: myelodysplastic syndrome, sTFR: soluble transferrin receptor.
Figure 1. Correlation between hepcidin and sTFR.
Table 2. Correlation between hepcidin and other parameters
in MDS.
Parameter Correlation p-value
coefficient
Ferritin -0.165 0.47
Hb 0.15 0.5
sTFR 0.45 0.03
Age -0.04 0.84
No. of transfused
blood units
sTFR: soluble transferrin receptor.
0.31 0.16
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Turk J Hematol 2014;31:394-398
Table 3. Comparison of different parameters in the 3 main types of MDS.
Parameters RCMD RAEB Hypoplastic MDS p
Hepcidin (ng/mL) 66.6 80.1 22.57 0.13
sTFR (nmol/L) 47.5 66.01 26.2 0.5
Ferritin (ng/mL) 527.3 676.8 434.5 0.7
MDS: myelodysplastic syndrome, RAEB: refractory anemia with excess blasts, RCMD: refractory cytopenia with multilineage dysplasia, sTFR, soluble transferrin receptor.
transfusion begins [9,10]. Moreover, MDS is characterized
by iron overload secondary to blood transfusion. However,
its impact on stimulation of pro-hepcidin release to inhibit
iron absorption is less than the erythroid drive suppressing its
release, as shown from our earlier results [5].
In this work, we included newly diagnosed (within 6
months of diagnosis) MDS cases to limit the impact of overtransfusion
on hepcidin levels. Furthermore, blood samples
were drawn at least 5 days after the last transfusion to abolish
the effect of acute transfusion on hepcidin expression.
We found hepcidin levels higher in MDS cases in
comparison to the control group, but this difference was not
statistically significant, which could be attributed to the small
number of patients studied.
Our results are in line with those of Qin et al., who found
that both hepcidin and serum ferritin levels in MDS patients,
regardless of transfusion dependency or the number of blood
transfusions, were higher than those of healthy controls
[11]. Our findings suggest that iron overload is not related
to defective hepcidin release but is rather associated with
ineffective erythropoiesis and blood transfusion.
In another study using SELDI-TOF MS for hepcidin assay,
serum hepcidin levels were measured to be slightly higher in
MDS patients than in controls, but this difference did not reach
statistical significance. Nevertheless, the hepcidin/ferritin
ratio was significantly lower for the whole MDS population
as compared to the controls, which is not consistent with our
study in which the ratio was higher in MDS cases [8]. This
could be explained by the higher mean ferritin levels of the
MDS population in that study, which also included heavily
transfused cases.
Ganz et al. reported that serum hepcidin was high in
low-grade MDS patients in correlation with their iron and
oxidative status, and that it was further increased by treatment
with deferasirox. They concluded that the hepcidin level
represented a balance between the stimulating effect of iron
overload and the inhibitory effects of erythropoietic activity
and oxidative stress. These preliminary findings favor the
rationale for iron chelation therapy in such patients [12]. Our
results revealed no correlation between hepcidin level and
ferritin in patients with MDS in the context of non-heavily
transfused patients.
Qin et al. worked on heavily transfused MDS and found
that the increase of hepcidin was not in synchrony with
the increase in serum ferritin levels secondary to blood
transfusion when the number of blood transfusions exceeded
24 U. Hepcidin levels showed a negative relationship to serum
ferritin, reflecting the decreased ability of hepcidin to inhibit
body iron absorption during the increase of blood transfusion,
which finally led to iron overload. Dynamic monitoring
of the hepcidin concentration could help in predicting the
occurrence of iron overload in transfusion-dependent MDS
patients [11].
The current data may indicate that there is no correlation
between hepcidin and serum ferritin in MDS cases, and thus
hepcidin may not be a main player in iron overload in MDS.
A possibility of peripheral unresponsiveness to hepcidin in
MDS or failure of production may be the underlying cause,
but further studies are required.
When divided into RCMD, RAEB, and hypoplastic MDS
groups, the highest levels of hepcidin were in the RAEB group,
indicating marked activity in the bone marrow, followed by
the RCMD and the hypocellular MDS groups. However, the
difference among different subgroups in terms of hepcidin,
ferritin, or sTFR level did not reach statistical significance.
Santini et al. found that mean hepcidin levels were
consistently heterogeneous across different MDS subtypes,
with the lowest levels in refractory anemia with ringed
sideroblasts (1.43 nmol/L) and the highest in the RAEB (11.3
nmol/L) (p=0.003) [8].
Conclusion
Iron overload in MDS involves many players. Further
studies are required to reveal the causes of failure in
erythropoiesis or the peripheral unresponsiveness to hepcidin
in MDS cases.
Acknowledgments
Special thanks to all members of the Hematology Clinic
of Cairo University for their help in collection of data. The
researchers were given funding from Cairo University to
import ELISA kits for hepcidin assay.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
397

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El Husseiny MN, et al: Iron Status in Myelodysplasia
References
1. Dreyfus F. The deleterious effects of iron overload in patients
with myelodysplastic syndromes. Blood Rev 2008;22:29-34.
2. Davis SL, Littlewood TJ. The investigation and treatment of
secondary anaemia. Blood Rev 2012;26:65-71.
3. Murphy PT, Mitra S, Gleeson M, Desmond R, Swinkels
DW. Urinary hepcidin excretion in patients with low grade
myelodysplastic syndrome. Br J Haematol 2009;144:451-
452.
4. Winder A, Lefkowitz R, Ghoti H, Leiba M, Ganz T, Nemeth E,
Rachmilewitz EA. Urinary hepcidin excretion in patients with
myelodysplastic syndrome and myelofibrosis. Br J Haematol
2008;142:669-671.
5. El Husseiny NM, Matter MM, Sabry RM, Amin IS. Serum
prohepcidin level in myelodysplasia. Scand J Clin Lab Invest
2010;70:343-346.
6. Kroot JJ, Laarakkers CM, Geurts-Moespot AJ,
Grebenchtchikov N, Pickkers P, van Ede AE, Peters HP, van
Dongen-Lases E, Wetzels JF, Sweep FC, Tjalsma H, Swinkels
DW. Immunochemical and mass-spectrometry–based serum
hepcidin assays for iron metabolism disorders. Clin Chem
2010;56:1570-1579.
7. Koliaraki V, Marinou M, Vassilakopoulos TP, Vavourakis E,
Tsochatzis E, Pangalis GA, Papatheodoridis G, Stamoulakatou
A, Swinkels DW, Papanikolaou G, Mamalaki A. A novel
immunological assay for hepcidin quantification in human
serum. PLoS One 2009;4:4581.
8. Santini V, Girelli D, Sanna A, Martinelli N, Duca L, Campostrini
N, Cortelezzi A, Corbella M, Bosi A, Reda G, Olivieri O,
Cappellini MD. Hepcidin levels and their determinants in
different types of myelodysplastic syndromes. PLoS One
2011;6:23109.
9. Fleming MD. The regulation of hepcidin and its effects on
systemic and cellular iron metabolism. Hematology Am Soc
Hematol Educ Program 2008;151-158.
10. Nemeth E. Iron regulation and erythropoiesis. Curr Opin
Hematol 2008;15:169-175.
11. Qin Y, Liu H, Ruan S, Cai YF, You XF, Song GQ. Detection of
hepcidin in transfusion dependent myelodysplastic syndrome
patients and its clinical significance. Zhonghua Xue Ye Xue
Za Zhi 2011;32:758-761 (article in Chinese with English
abstract).
12. Ganz T, Olbina G, Girelli D, Nemeth E, Westerman
M. Immunoassay for human serum hepcidin. Blood
2008;112:4292-4297.
398

Case Report
DOI: 10.4274/tjh.2013.0082
Severe Myelotoxicity Associated with Thiopurine
S-Methyltransferase*3A/*3C Polymorphisms in a Patient
with Pediatric Leukemia and the Effect of Steroid Therapy
Pediatrik Bir Lösemi Olgusunda Tiyopurin S-Metiltransferaz
*3A/*3C Polimorfizmi ile İlişkili Ağır Miyelotoksisite-Steroid
Tedavisinin Etkisi
Burcu Fatma Belen1, Türkiz Gürsel1, Nalan Akyürek2, Meryem Albayrak3, Zühre Kaya1, Ülker Koçak1
1Gazi University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
2Gazi University Faculty of Medicine, Department of Pathology, Ankara, Turkey
3Kırıkkale University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
Abstract:
Myelosuppression is a serious complication during treatment of acute lymphoblastic leukemia and the duration of
myelosuppression is affected by underlying bone marrow failure syndromes and drug pharmacogenetics caused
by genetic polymorphisms. Mutations in the thiopurine S-methyltransferase (TPMT) gene causing excessive
myelosuppression during 6-mercaptopurine (MP) therapy may cause excessive bone marrow toxicity. We report the
case of a 15-year-old girl with T-ALL who developed severe pancytopenia during consolidation and maintenance
therapy despite reduction of the dose of MP to 5% of the standard dose. Prednisolone therapy produced a remarkable
but transient bone marrow recovery. Analysis of common TPMT polymorphisms revealed TPMT *3A/*3C.
Key Words: Myelosuppression, Thiopurine S-methyl transferase, Acute leukemia
Özet:
Miyelosupresyon, akut lenfoblastik lösemi tedavisinde görülen ciddi bir komplikasyon olup, miyelosupresyon süresi kemik iliği
yetmezlik sendromlarından veya genetik polimorfizmin yol açtığı ilaç farmakogenetiğinden etkilenmektedir. Merkaptopürin
metabolizasında yer alan Thiopurin s-metil transferaz (TPMT) enziminin azalmış aktivitesine neden olan polimorfizmleri artmış
kemik iliği toksisitesine yol açar. Burada, 15 yaşında TPMT *3A/*3C ve MTHFR polimorfizmleri saptanan ve konsolidasyon/
idame tedavisi boyunca MP’nin standart dozun %5’inde yoğun miyelosupresyon görülen ve steroid tedavisi ile geçici düzelme
saptanan bir T-ALL olgusu sunulmaktadır.
Anahtar Sözcükler: Miyelosupresyon, Thiopurin S-metil transferaz, Akut lösemi
Address for Correspondence: Burcu Fatma BELEN, M.D.,
Gazi University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
Gsm: +90 532 581 45 51 E-mail: draida@yahoo.com
Received/Geliş tarihi : March 6, 2013
Accepted/Kabul tarihi : April 22, 2013
399

Turk J Hematol 2014;31:399-402
Belen FB, et al: Myelotoxicity with TPMT *3A/*3C Polymorphisms
Introduction
Myelosuppression is a serious complication of
chemotherapy in children with acute lymphoblastic leukemia
(ALL). The duration and the severity of myelosuppression vary
with genetic polymorphisms affecting drug pharmacokinetics
and bone marrow failure syndromes [1,2]. The thiopurine
S-methyl transferase (TPMT) enzyme is involved in the
metabolism of 6-mercaptopurine (MP), a widely used
cytostatic agent in childhood ALL. The levels of active MP
metabolites are elevated during MP therapy in patients who
carry TPMT mutations with decreased enzyme activity such
as TPMT *2 (G238C), TPMT *3A (G460A and A719G),
and TPMT *3C (A719G), leading to excessive bone marrow
toxicity and being more profound in those with 2 as compared
to 1 nonfunctional allele [2,3,4,5,6]. The contribution of
methylenetetrahydrofolate reductase (MTHFR) mutations in
MP-induced myelosuppression has not been well established
[7,8]. We here describe the case of a 15-year-old girl with
ALL and TPMT *3A/*3C and MTHFR polymorphisms who
suffered from severe bone marrow suppression persisting
during the consolidation and maintenance therapy.
Case Presentation
A 15-year-old girl presented with a white blood cell
(WBC) count of 150x109/L, anemia, thrombocytopenia,
and mediastinal enlargement. A diagnosis of T-cell ALL
was made based on peripheral blood morphology and
immunophenotyping by flow cytometer. Karyotyping
disclosed t(11;14), but polymerase chain reaction (PCR) tests
for t(4;11) and t(9;21) were negative. She was treated with
the Berlin-Frankfurt-Münster (BFM) ALL-95 chemotherapy
protocol [9]. She received induction chemotherapy
uneventfully and achieved complete remission on day 33 with
full bone marrow recovery. Five days after receiving the first
5 days of Protocol Ib, which contained 6-MP at 60 mg/m 2 per
day orally, cytosine arabinoside (c-ARA) at 75 mg/m 2 /day for
4 doses, and a single dose of 1000 mg/m 2 cyclophosphamide,
her WBC count, absolute neutrophil count (ANC), platelet
count, and hemoglobin (Hb) level began to decrease and
reached a minimum at week 14 (WBC: 0.8x10 9 /L, ANC
:0x109/L; platelets: 3x10 9 /L; Hb: 5 g/dL). Chemotherapy was
stopped; granulocyte colony-stimulating factor (G-CSF) was
started at 5 µg/kg/day and increased to 10 µg/kg/day. Six weeks
later, WBC and ANC returned to normal but Hb level and
platelet count remained low. Bone marrow aspirations yielded
dry taps. TPMT genotyping for G238C, G460A, and A719G
was reported as negative. As WBC and ANC were within
normal limits, chemotherapy was restarted, but her counts
rapidly dropped (Figure 1). She remained pancytopenic for
a further 6-week period, during which chemotherapy was
stopped, and numerous platelet and erythrocyte transfusions
were given. Bone marrow biopsy showed cellularity of 5%
with no residual leukemia and/or fibrosis. PCR analysis for
parvovirus B19, Epstein-Barr virus, and cytomegalovirus
and the diepoxybutane (DEB) test were negative. Because
of protracted pancytopenia, the rest of Protocol Ib and
intensification blocks were omitted and maintenance therapy
with oral 6-MP and methotrexate (MTX) was started at
25% of protocol doses. Absolute neutrophil count dropped
and remained below 0.8x109/mm 3 despite G-CSF therapy.
Genotyping for MTHFR revealed heterozygousity for C677T
and A1298C polymorphisms. We were informed that the
patient had TPMT *3A/*3C polymorphisms; the previous
report of wild-type TPMT was a transcription error. The doses
of 6-MP and MTX were reduced to 10% of protocol doses, but
the patient remained severely pancytopenic and transfusiondependent.
Bone marrow biopsy showed profound
hypocellularity with occasional hematopoietic hot points and
abundant fat cells, resembling aplastic anemia. Chemotherapy
was stopped and oral prednisolone was started at a dose of 60
mg/m 2 per day. WBC and platelet counts increased gradually
starting from the second week, and bone marrow aspirate
became normocellular and free of leukemic blasts at the end of
30 days of steroid therapy. Bone marrow biopsy showed 40%
Figure 1. Absolute neutrophil counts, hemoglobin levels, and
platelet counts during ALL BFM-95 chemotherapy.
ANC: absolute neutrophil count, Hb: hemoglobin, Plt: platelet count, CCP:
cytosine arabinoside + 6-mercaptopurine treatment, CP: cyclophosphamide,
G-CSF: granulocyte colony-stimulating factor, GC: glucocorticoid
(prednisolone), Pr M: Protocol M-BFM 95, Pr II: Protocol II-BFM-95. Blanks
at the right end of the figure represent chemotherapy cessation due to
hyperglycemia and hypertriglyceridemia during Protocol II.
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Belen FB, et al: Myelotoxicity with TPMT *3A/*3C Polymorphisms
Turk J Hematol 2014;31:399-402
cellularity without residual blasts. As blood counts returned to
normal limits, intensification therapy with 4 blocks of MTX at
5 g/m 2 /day and 6-MP at 2.5 mg/m 2 /day (5% of protocol dose)
was given over the next 54 days. During this period, WBC
count and ANC remained between 2 and 3x10 9 /L and platelet
counts could be kept above 10x10 9 /L by weekly transfusions
(Figure 1). MTX levels were calculated at 24, 36, 42, 48, and
54 h after infusion of MTX as below the highest upper limit to
give additional folinic acid rescue. Reinduction therapy with
vincristine, dexamethasone, L-asparaginase, and doxorubicine
caused profound pancytopenia complicated with prolonged
febrile episodes, severe hyperglycemia, and liver dysfunction.
Therefore, the second part of the reinduction therapy was
omitted, and maintenance therapy was restarted at 10% of
standard doses. She completed the 5-week maintenance
therapy with 6-MP and MTX doses ranging from 5% to
10% and from 8% to 16%, respectively. After termination of
maintenance chemotherapy, blood counts gradually increased
and reached normal range within 3 months. Informed consent
was obtained.
Discussion and Review of the Literature
Following intensive chemotherapy, blood counts recover
within 2 to 4 weeks in most cases of ALL. Longer periods
of bone marrow suppression are rare and can be caused by
abnormalities of drug disposition pathways or congenital
bone marrow failure syndromes with myelodysplasia. A
clear relation with excessive bone marrow toxicity has
been established only for thiopurine drugs and TPMT
polymorphisms [1,2,3,4,5,6,10]. Patients homozygous or
compound heterozygous for a nonfunctional TPMT allele
develop pancytopenia 2 to 4 weeks after starting oral 6-MP
and recover within 2-6 weeks [11,12]. The longest duration
of pancytopenia was 137 days in an 8-year-old boy with ALL
who was homozygous for TPMT *3A/*3A [13].
Bone marrow suppression in the present case with TPMT
*3A/*3C polymorphisms was more severe as compared to
previously described patients with 2 nonfunctional TPMT
alleles. Pancytopenia developed shortly after introduction
of 6-MP and persisted during maintenance therapy,
despite reducing both 6-MP and MTX doses to 5% to 10%.
Interruption of chemotherapy for 6-8 weeks and G-CSF
therapy resulted in ANC recovery initially without significant
increase in Hb levels or platelet counts, but the duration of
bone marrow suppression was prolonged as 6-MP exposures
increased, suggesting that myelotoxicity is dose-dependent.
However, we did not investigate additional single nucleotide
polymorphisms involved in thiopurine metabolism, such
as inosine triphosphate pyrophosphatase, that might have
been responsible for extreme bone marrow suppression in
our patient [14]. She also had MTHFR C677T and A1298C
polymorphisms, which cause reduced MTHFR activity,
leading to decreased production of S-adenosylmethionine, a
protector of the TPMT enzyme [15]. Karas-Kuzelicki et al.
reported increased myelotoxicity in children with ALL who
were heterozygous for at least one low-activity TPMT allele
and for C677T and/or A1298C polymorphisms in the MTHFR
gene [7]. In contrast, another study found lower frequency
of severe myelotoxicity in pediatric ALL patients having
both TPMT and C677T polymorphisms [8]. Interestingly,
we did not observe excessive hematological toxicity during
intensification therapy with high-dose (5 g/m2) MTX
combined with low-dose MP (2.5% of protocol dose) in our
patient, suggesting that compound heterozygosity for C677T
and A1298C is not an additional risk factor for hematotoxicity
in children with TPMT polymorphisms. An interesting finding
in the present case is a quick bone marrow recovery induced
by glucocorticoid therapy. Bone marrow cellularity increased
from 5% at the beginning to 45% at the end of 4 weeks of 2
mg/kg prednisolone administration. Although steroid therapy
is effective in the treatment of immune-mediated bone marrow
suppression, its role in chemotherapy-induced bone marrow
hypoplasia has not been well studied. A short course of highdose
methylprednisolone therapy was reported to increase
CD34 (+) progenitor cells and shorten chemotherapy-induced
neutropenia in children with leukemia [16,17]. The molecular
mechanisms of steroid effects on bone marrow regeneration
need to be illuminated.
Children with Fanconi anemia (FA) may experience
severe bone marrow toxicity with alkylating agents like
cyclophosphamide and busulphan [2,18]. Cyclophosphamide
causes chromosomal breaks in FA patients. A recent study
showed that cyclophosphamide-specific interstrand DNA
cross-links were increased 15-fold in FA patients compared
to non-FA patients [19]. Our patient had received high-dose
cyclophosphamide in addition to 6-MP one week before
development of initial bone marrow hypoplasia. She had
none of the main clinical or laboratory features of FA, such
as congenital defects, developmental abnormalities, elevated
HbF level, or increased chromosomal fragility. Patients with
myelodysplasia also show delayed bone marrow recovery
after chemotherapy. Several cases of T-cell ALL have been
described in patients with myelodysplasia associated with
germline RUNX-1 mutation or microdeletion of 21q22
resulting in RUNX-1 deficiency [20]. The conventional
karyotyping performed for our patient is not able to detect
such a small deletion, but absence of thrombocytopenia
history before development of leukemia and rapid bone
marrow regeneration without dysplastic changes and
complete hematologic reconstitution at day 33 of remission
induction therapy exclude this possibility. Patients who are
compound heterozygous for TPMT *3A/3C may have severe
401

Turk J Hematol 2014;31:399-402
Belen FB, et al: Myelotoxicity with TPMT *3A/*3C Polymorphisms
bone marrow hypoplasia even with minimal amounts of MP.
Further investigation of other genetic factors involved in
MP metabolism and measurement of the intracellular levels
of thioguanine nucleotides may help in better treatment of
chemotherapy-induced myelosuppression.
Conclusion
Compound heterozygosity for TPMT *3A/3C may
be associated with severe bone marrow hypoplasia, even
with minimal amounts of MP, in children with ALL. The
role of glucocorticoids on bone marrow regeneration after
chemotherapy should be investigated further.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
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1. Meeker ND, Yang JJ, Schiffman JD. Pharmacogenomics
of pediatric acute lymphoblastic leukemia. Expert Opin
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2. Borriello A, Locasciulli A, Bianco AM, Criscuolo M, Conti V,
Grammatico P, Cappellacci S, Zatterale A, Morgese F, Cucciolla
V, Delia D, Della Ragione F, Savoia A. A novel Leu153Ser
mutation of the Fanconi anemia FANCD2 gene is associated
with severe chemotherapy toxicity in a pediatric T-cell acute
lymphoblastic leukemia. Leukemia 2007;21:72-78.
3. Lennard L, Gibson BE, Nicole T, Lilleyman JS. Congenital
thiopurine methyltransferase deficiency and 6-mercaptopurine
toxicity during treatment for acute lymphoblastic leukaemia.
Arch Dis Child 1993;69:577-579.
4. McLeod HL, Coulthard S, Thomas AE, Pritchard SC, King
DJ, Richards SM, Eden OB, Hall AG, Gibson BE. Analysis
of thiopurine methyltransferase variant alleles in childhood
acute lymphoblastic leukaemia. Br J Haemol 1999;105:696-
700.
5. Krynetski, EY, Evans WE. Genetic polymorphism of
thiopurine S-methyltransferase: molecular mechanisms and
clinical importance. Pharmacology 2000;61:136-146.
6. Relling MV, Hancock ML, Rivera GK, Sandlund JT, Ribeiro
RC, Krynetski EY, Pui CH, Evans WE. Mercaptopurine
therapy intolerance and heterozygosity at the thiopurine
S-methyltransferase gene locus. J Natl Cancer Inst
1999;91:2001-2008.
7. Karas-Kuzelicki N, Jazbec J, Milek M, Mlinaric-Rascan I.
Heterozygosity at the TPMT gene locus, augmented by
mutated MTHFR gene, predisposes to 6-MP related toxicities
in childhood ALL patients. Leukemia 2009;23:971-974.
8. Costea I, Moghrabi A, Laverdiere C, Graziani A, Krajinovic
M. Folate cycle gene variants and chemotherapy toxicity
in pediatric patients with acute lymphoblastic leukemia.
Haematologica 2006;91:1113-1116.
9. Kaya Z, Gursel T, Bakkaloglu SA, Kocak U, Atasever T, Oktar
SO. Evaluation of renal function in Turkish children receiving
BFM-95 therapy for acute lymphoblastic leukemia. Pediatr
Hematol Oncol 2007;24:257-267.
10. Albayrak M, Konyssova U, Kaya Z, Gursel T, Guntekin S, Percin
EF, Kocak U. Thiopurine methyltransferase polymorphisms
and mercaptopurine tolerance in Turkish children with
acute lymphoblastic leukemia. Cancer Chemother Pharmacol
2011;68:1155-1159.
11. Evans WE, Horner M, Chu YQ, Kalwinsky D, Roberts WM.
Altered mercaptopurine metabolism, toxic effects, and dosage
requirement in a thiopurine methyltransferase-deficient child
with acute lymphocytic leukemia. J Pediatr 1991;119:985-
989.
12. Andersen JB, Szumlanski C, Weinshilboum RM, Schmiegelow
K. Pharmacokinetics, dose adjustments and 6-mercaptopurine
/methotrexate drug interactions with thiopurine
methyltransferase deficiency. Acta Paediatr 1998;87:108-111.
13. McBride KL, Gilchrist GS, Smithson WA, Weinshilboum
RM, Szumlanski CL. Severe 6-thioguanine-induced marrow
aplasia in a child with acute lymphoblastic leukemia and
inherited thiopurine methyltransferase deficiency. J Pediatr
Hematol Oncol 2000;22:441-445.
14. Adam de Beaumais T, Fakhoury M, Medard Y, Azougagh
S, Zhang D, Yakouben K, Jacqz-Aigrain E. Determinants of
mercaptopurine toxicity in paediatric acute lymphoblastic
leukemia maintenance therapy. Br J Clin Pharmacol
2011;71:575-584.
15. Milek M, Karas Kuzelicki N, Smid A, Mlinaric-Rascan I.
S-adenosylmethionine regulates thiopurine methyltransferase
activity and decreases 6-mercaptopurine cytotoxicity in MOLT
lymphoblasts. Biochem Pharmacol 2009;77:1845-1853.
16. Cetin M, Hiçsönmez G, Tuncer AM, Kansu E, Canpynar H.
The effect of short-course high-dose corticosteroid therapy
on peripheral blood CD34+ progenitor cells in children with
acute leukemia. Exp Hematol 1996;24:1191-1194.
17. Elmas SA, Cetin M, Tuncer M, Hicsonmez G. Myeloprotective
effect of short course high dose methyl prednisolone
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myeloblastic leukemia. Am J Hematol 2005;80:1-5.
18. Goldsby RE, Perkins SL, Virshup DM, Brothman AR, Bruggers
CS. Lymphoblastic lymphoma and excessive toxicity from
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Pediatr Hematol Oncol 1999;21:240-243.
19. Johnson LA, Malayappan B, Tretyakova N, Campbell C,
MacMillan ML, Wagner JE, Jacobson PA. Formation of
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20. Kundu M, Compton S, Garrett-Beal L, Stacy T, Starost MF,
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402

Case Report
DOI: 10.4274/tjh.2013.0090
Intravascular Large B-Cell Lymphoma Diagnosed on Prostate
Biopsy: A Case Report
Prostat Biopsisinde Tanı Konulan İntravasküler Büyük B Hücreli
Lenfoma: Olgu Sunumu
Nazan Özsan1, Banu Sarsık1, Asu Fergün Yılmaz2, Adnan Şimşir3, Ayhan Dönmez2
1Ege University Faculty of Medicine, Department of Pathology, İzmir, Turkey
2Ege University Faculty of Medicine, Department of Hematology, İzmir, Turkey
3Ege University Faculty of Medicine, Department of Urology, İzmir, Turkey
Abstract:
Intravascular large B-cell lymphoma (IVLBCL) is a very rare type of non-Hodgkin lymphoma, usually affecting elderly
patients and characterized by selective infiltration of neoplastic cells within blood vessels’ lumina. IVLBCL diagnosed
with prostatic involvement is extremely rare. We report a patient of 65 years old, having mostly neurological complaints
but diagnosed with IVLBCL upon histopathological examination of transurethral prostate resection material, which
revealed large neoplastic cell infiltration totally limited within the lumens of small vessels. By immunohistochemistry,
neoplastic cell infiltration was positive with MUM1, bcl-6, and bcl-2 and negative with ALK1, CD10, and CD30, with
a high Ki-67 proliferation index. CD34 and CD31 staining showed expression in endothelial cells, highlighting the
intravascular nature of neoplastic infiltrate. The patient unfortunately refused to receive treatment and died of the
disease 8 months after the diagnosis. IVLBCL, though very rare, should be considered in differential diagnosis of all
organ biopsies with intravascular infiltration. Further improvements in the understanding of the pathogenesis and
biology of this rare type of lymphoma are mandatory.
Key Words: Non-Hodgkin lymphoma, Intravascular large B-cell lymphoma, Prostate, Non-germinal center B-cell
Özet:
İntravasküler büyük B hücreli lenfoma (İVBBHL), non-Hodgkin lenfomaların nadir bir tipidir, genellikle ileri yaşta
görülür, ve neoplastik hücrelerin damar lümeni içerisinde seçici infiltrasyonu ile karakterlidir. Prostat tutulumu ile
tanı konan İVBBHL olguları ise çok nadirdir. Altmış beş yaşında, daha çok nörolojik şikayetleri olan, ancak transüretral
prostat rezeksiyon materyalinin histopatolojik incelemesinde, tamamen küçük damar lümenleri içerisinde sınırlı
neoplastik büyük hücre infiltrasyonunun görülmesi ile tanı konan bir olguyu sunuyoruz. Neoplastik hücre infiltrasyonu
immunhistokimyasal incelemede MUM1, bcl-6 ve bcl-2 ile pozitif, ALK1, CD10, CD30 ile negatif saptandı, Ki67
proliferasyon indeksi yüksekti. CD34 ve CD31 endotelial hücrelerde pozitif olup, neoplastik infiltrasyonun damar içi
yerleşimini belirgin olarak ortaya koydu. Hasta, ne yazık ki tedavi almayı kabul etmedi ve sekiz ay içerisinde hastalık
nedeniyle kaybedildi. IVLBCL, az görülmekle birlikte, intravasküler infiltrasyon içeren tüm organ biopsilerinde
ayırıcı tanı içerisinde yer almalıdır. Bu nadir lenfoma tipinin patogenez ve biyolojisinin aydınlatılmasına ihtiyaç
duyulmaktadır.
Anahtar Sözcükler: Non-Hodgkin lymphoma, İntravasküler büyük B hücreli lenfoma, Prostat, Non-germinal merkez B
hücre
Address for Correspondence: Nazan ÖZSAN, M.D.,
Ege University Faculty of Medicine, Department of Pathology, İzmir, Turkey
Phone: +90 232 388 10 25 E-mail: nazanozsan@yahoo.com
Received/Geliş tarihi : March 14, 2013
Accepted/Kabul tarihi : April 2, 2013
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Özsan N, et al: Intravascular Large B Cell Lymphoma
Introduction
Intravascular large B-cell lymphoma (IVLBCL) is a very
rare type of non-Hodgkin lymphoma and is characterized by
selective infiltration of neoplastic cells within blood vessels’
lumina. IVLBCL is an aggressive disease, usually affecting
elderly patients with a poor prognosis [1].
Prostatic involvement in IVLBCL is extremely rare and has
been described in only a few case reports. We hereby report
a 65-year-old male patient who presented with neurological
symptoms and was diagnosed with IVLBCL based on
transurethral prostate resection (p-TUR) material.
Case Presentation
A 65-year-old man was admitted to the hospital with
complaints of cervical and back pain. His past history
revealed no remarkable illnesses, and he had no evidence of
human immunodeficiency virus infection or other causes of
immunodeficiency.
Cervical spine magnetic resonance (MR) imaging showed
signs consistent with degenerative discopathies at multiple
levels and an increase in signals at the level of the conus
medullaris, consistent with myelitis. Informed consent was
obtained.
The patient also had complaints indicating lower urinary
tract symptoms, such as difficulty in urinating.
Laboratory findings showed an increase in lactate
dehydrogenase (LDH) levels (682 U/L; reference scale: 240-
480 U/L) and a mild decrease in platelet count (83,000/µL;
reference range: 150,000-450,000/µL). The prostate-specific
antigen (PSA) level was in normal limits (PSA: 2.37 ng/mL;
reference range: 0.15). Ultrasonography revealed
enlargement in prostatic dimensions of 41x40x36 mm in
size. p-TUR with spinal anesthesia was performed. After the
surgery, the patient developed paraplegia and urinary and
fecal incontinence. Lumbar spine MR imaging done after the
surgery revealed signs consistent with lumbar spondylolysis,
degenerative changes at multiple levels, and an increase of
signals in the conus medullaris, which may reveal myelitis. He
was then given prednisolone at 1 g/day for 10 days with the
diagnosis of myelitis upon neurology consultation.
Histopathological examination of the p-TUR specimen
revealed large neoplastic cell infiltration totally limited within
the lumens of small vessels in the stroma, while acinar and
glandular structures were all benign.
Immunohistochemical analysis was performed on
paraffin-embedded tissue sections with an automated stainer
(Ventana Benchmark XT, Ventana Medical Systems, Tucson,
AZ, USA) according to protocol. A streptavidin-biotinperoxidase
detection system with diaminobenzidine as a
chromogen was used to visualize bound secondary antibodies.
The intravascular neoplastic cells were positive for CD20 and
negative for CD3 and pan-cytokeratin. The following panel
of antibody testing was then performed: CD10, bcl-6, bcl-
2, IRF4/MUM1, CD30, Ki-67, CD34, ALK, and CD31. The
antibodies were scored as positive when >30% of tumor cells
showed immunoexpression. Neoplastic cell infiltration was
positive with MUM1, bcl-6, and bcl-2 and negative with ALK1,
CD10, and CD30. The Ki-67 proliferation index was high,
showing expression in about 90% of neoplastic large cells.
CD34 and CD31 stainings showed expression in endothelial
cells, highlighting the intravascular nature of the neoplastic
infiltrate. In situ hybridization analysis was also performed
using oligonucleotides complementary to Epstein–Barr early
RNA transcripts in tissue sections of paraffin-embedded tissue
in the same automated stainer (Ventana Medical Systems),
which revealed negative results. The immunohistochemical
expressions (IRF4/MUM1 and bcl-6 positivity, with CD10
negativity) revealed a non-germinal center B cell (non-GCB)
phenotype when classified according to the Hans criteria [2].
The patient was diagnosed with IVLBCL from the p-TUR
material.
Figure 1. A) Infiltration of neoplastic large cells in the
lumen of small vessels in transurethral prostate resection
material (hematoxylin and eosin, original magnification:
x200) by immunohistochemistry; B) CD31 staining with
expression in endothelial cells highlighted the intravascular
nature of neoplastic infiltrate (immunoperoxidase, original
magnification: x400); C) Neoplastic infiltration is negative with
cytokeratine, while benign glandular structures are positive
(immunoperoxidase, original magnification: x200); D) Ki67
staining showed a high proliferation index in neoplastic cells
(immunoperoxidase, original magnification: x200).
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Turk J Hematol 2014;31:403-407
The patient was hospitalized in the hematology department
with a diagnosis of lymphoma. No enlarged superficial lymph
nodes were found on physical examination. Positron emission
tomography-computed tomography (PET-CT) showed an
increase in fluorodeoxyglucose signals in both kidneys, which
was interpreted as consistent with an inflammatory origin.
Upper abdominal ultrasonography revealed mild splenomegaly
(135 mm). The patient was given prednisolone at 1 g/day for
10 days, when bone marrow biopsy was performed. Bone
marrow biopsy revealed no infiltration of lymphoma from
either morphology or immunohistochemistry. R-CHOP
chemotherapy was planned, but the patient refused to receive
therapy and was discharged at his request. He received no
therapy for IVLBCL and died from the disease 8 months after
the diagnosis.
Discussion and Review of the Literature
In the current World Health Organization classification of
hematopoietic neoplasms, IVLBCL is defined as a rare type
of extranodal large B-cell lymphoma characterized by the
selective infiltration of neoplastic cells in the lumina of vessels
and capillaries, with the exception of large arteries and veins
[3]. The disease is widely disseminated in extranodal sites: the
bone marrow, central nervous system, skin, lungs, liver, and
spleen are the most common sites of involvement [4]. Lymph
node infiltration and lymphadenopathy are usually absent
[5]. The clinical signs and symptoms are variable, related
to the site of involvement. Neoplastic cells are rarely seen in
bone marrow and peripheral blood smears and so IVLBCL
is very difficult to diagnose; most of the cases reported
have been confirmed by autopsy or cutaneous biopsies [6].
IVLBCL diagnosed in prostate specimens is extremely rare
Figure 2. Neoplastic large cells filling the vessels are
strongly positive with CD20 (immunoperoxidase, original
magnification: x200).
in the literature, usually reported as single cases; to the
best of our knowledge, this is the 10th such case reported
[1,7,8,9,10,11,12]. Furthermore, none of the patients in the
study by Murase et al., with a large series of 96 patients, were
diagnosed with prostatic involvement, indicating the rarity of
infiltration in this site [6].
All reported cases of primary IVLBCL of the prostate are in
elderly patients aged above 60 years [10], and the median age
defined for all IVLBCL cases is 67 years (range: 13-85 years)
[4].
There are no specific laboratory findings indicating IVLBCL,
but most patients were reported to display few pathologic
findings in their complete blood counts, which should raise
suspicion. Ferreri et al., in the study of a series of 38 patients,
reported anemia in nearly 65% of patients, increased LDH and
β2 microglobulin levels in more than 80% of patients, and an
elevated sedimentation component in 14% of patients [1]. Our
patient had an increased LDH level and mild thrombocytopenia.
He had complaints indicating lower urinary tract symptoms,
which led to a urinary tract examination. No increase in PSA
levels was found, but ultrasonography revealed enlargement in
prostatic dimensions, leading to p-TUR surgery. The diagnosis
of IVLBCL was established based on histopathological and
immunohistochemical assessment of the biopsy. Neoplastic
cell infiltration was totally limited within the lumens of small
vessels in the stroma, within benign acinar and glandular
structures. Neoplastic cell infiltration was positive with CD20,
MUM1, bcl-6, and bcl-2 and negative with ALK1, CD10,
CD30, and cytokeratin, with a high Ki-67 proliferation index.
CD34 and CD31 staining with expression in endothelial cells
highlighted the intravascular nature of the neoplastic infiltrate
(Figures 1 and 2). The immunohistochemical profile of
infiltration revealed a non-GCB cell phenotype (negative for
CD10 and positive for IRF4/MUM1 and bcl-6) when classified
according to the Hans criteria. Kanda et al. suggested that most
IVLBCL cases might originate from post-germinal center cells,
based on the presence of somatic mutation in variable regions
of immunoglobulin heavy chain genes [13]. Subsequent
studies supported their assertion as most IVLBCL cases have
been reported to be of non-GCB cell origin [5,6].
Our patient had no enlarged lymph nodes; bone marrow
biopsy showed no infiltration of lymphoma. Upper abdominal
ultrasonography revealed mild splenomegaly, but PET-CT
showed no findings consistent with extra sites of infiltration;
according to these findings, he had stage 1E disease. In a
study of 38 intravascular lymphoma patients, Ferreri et al.
reported that 40% of the patients diagnosed in vivo had stage
1E disease according to the Ann Arbor staging system, but
a disseminated infiltration was shown by autopsy in some
stage I disease patients when death occurred a short time after
diagnosis, highlighting the limitations of staging procedures
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Turk J Hematol 2014;31:403-407
Özsan N, et al: Intravascular Large B Cell Lymphoma
in intravascular lymphoma patients [1,14]. The relatively high
proportion of false negativity in classical staging procedures
can be attributed to the fact that IVLBCL infiltration may
usually be seen without tumor masses and apparent signs of
involvement or lymphadenopathy [15].
The clinical manifestations of IVLBCL are extremely
variable and symptoms are mostly related to the involved
organ. Interestingly, clinical manifestations of the disease
have been shown to differ between 2 distinct geographical
areas. In Asian countries, hemophagocytic syndrome,
bone marrow involvement, hepatosplenomegaly, fever, and
thrombocytopenia have been documented at high frequencies,
while central nervous system and skin involvements are
predominantly seen in European countries [1,16]. Despite
the defined geographical differences, neurological symptoms
at initial diagnosis were reported in high incidences in both
the Asian and Western types of the disease at 25% and 36%,
respectively [1,17]. Among the few cases reported with
prostatic involvement, 2 patients presented with neurological
signs indicating spinal cord lesions [8,9]. Our patient had some
neurological symptoms interpreted as myelitis according to MR
findings, and following p-TUR surgery with spinal anesthesia,
paraparesis developed. Whether these neurological symptoms
were due to real neurological pathologies or to the invasion
of tumor cells into the central nervous system or peripheral
nerves remains unclear because an autopsy was not performed.
The disease has an aggressive behavior, usually with a short
outcome and fatal course [1]. The use of rituximab-containing
chemotherapy regimens for the treatment of IVLBCL has been
reported to improve outcomes [17,18].
Ferreri et al. reported overall survival at 3 years as 81%
in 33 patients receiving immunochemotherapy [18]. Highdose
chemotherapy with the support of autologous stem cell
transplantation was shown to have efficacy in several reports
[19,20]. Despite all treatment modalities, our patient refused
to receive treatment for lymphoma and unfortunately died of
the disease 8 months after the diagnosis.
IVLBCL, though very rare, should be considered in
differential diagnosis for elderly patients with elevated LDH
levels, fever of unknown origin, and unexplained neurological
symptoms. As for prostatic involvement, lower urinary tract
obstruction symptoms can be seen, but an elevated level of
PSA is not a common finding for lymphoma infiltration
in the prostate, including rare IVLBCL cases [21]. Biopsy
and immunohistochemical assessment are required for the
diagnosis. Early diagnosis can result in a better outcome with
the recent treatment options. Further improvements in the
understanding of the pathogenesis and biology of this rare
type of lymphoma are mandatory to achieve better outcomes
for IVLBCL patients.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
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Intravascular lymphoma presenting with neurological signs
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Case Report
DOI: 10.4274/tjh.2013.0049
Primary Splenic Angiosarcoma Revealed by Bone Marrow
Metastasis
Kemik İliği Metastazı ile Açığa Çıkan Primer Splenik Anjiosarkom
Soumaya Anoun1, Sofia Marouane2, Asmae Quessar1, Said Benchekroun1
1Hopital 20 AOUT, Clinic of Hematology and Pediatric Oncology, Casablanca, Morocco
2Hopital Ibn Rochd, Clinic of Histopathology, Casablanca, Morocco
Abstract:
Primary splenic angiosarcomas are the most common malignant non-hematopoietic tumors of the spleen. Metastatic
diseases were found in 69% of patients in a reported series but the incidence of bone marrow involvement is unclear.
We report a rare case of a 25-years-old Moroccan woman with unsuspected primary splenic angiosarcoma revealed
by bone marrow metastasis. She presented with serious anemia and splenomegaly. Bone marrow biopsy revealed
proliferating spindle cells. Computed tomography scanning showed an enlarged spleen with heterogeneous lesions.
Splenectomy was performed and retrospective histological study of the spleen confirmed the diagnosis. She died 1
year after splenectomy.
Key Words: Angiosarcoma, Splenomegaly, Bone marrow infiltration
Özet:
Primer splenik anjiosarkom dalağın hematolojik olmayan tümörlerinden en sık karşılaşılanıdır. Yayınlanmış serilerde
metastaz %69 olarak belirtilmişse de kemik iliği metastazının sıklığı tam bilinmemektedir. Biz Faslı bir kadın hastada
kemik iliği metastazı ile açığa çıkan daha önceden şüphelenilmemiş bir primer splenik anjiosarkom vakasını rapor
etmek istiyoruz. Yirmi beş yaşındaki hastanın ciddi anemi ve splenomegalisi mevcuttu. Kemik iliği biyopsisinde kemik
iliği alanlarının yerini prolifere olmuş iğsi hücrelere bıraktığı gözlendi. Bilgisayarlı Tomografide büyümüş dalak
içinde heterojen lezyonlar görüldü. Splenektomi yapıldı ve dalak üzerinde yapılan histolojik çalışma primer splenik
anjiosarkom tanısını doğruladı. Hasta kemoterapi aldı fakat splenektomiden 1 yıl sonra metastazdan öldü.
Anahtar Sözcükler: Anjiosarkom, Splenomegali, Kemik iliği tutulumu
Address for Correspondence: Soumaya ANOUN, M.D.,
Hopital 20 AOUT, Clinic of Hematology and Pediatric Oncology, Casablanca, Morocco
Phone: +212 662 39 11 04 E-mail: soumaya.anoun@gmail.com
Received/Geliş tarihi : February 12, 2013
Accepted/Kabul tarihi : March 29, 2013
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Anoun S, et al: Primary Splenic Angiosarcoma
Turk J Hematol 2014;31:408-410
Introduction
Bone marrow is one of the common sites to be involved
with solid tumors that metastasize via the bloodstream.
Micrometastases can be demonstrated in the bone marrow
of 30%-75% of patients with common malignancies [1].
Metastases involved in cortical bones often present with bony
pain, pathologic fracture, and hypercalcemia [2]. Marrow
involvement appears to be a prerequisite for the development,
as bony metastases occur at the sites with hematopoietic
marrow [2]. Extensive infiltration of the bone marrow
may compromise hematopoietic functions. Hematologic
abnormalities suggestive of marrow infiltration are peripheral
cytopenia and leukoerythroblastic changes, and their
occurrence is largely due to marrow replacement by tumor
infiltration and reactive marrow fibrosis [2].
Bone marrow aspirate and biopsy can be used to easily
diagnose medullary metastases. The incidence of bone marrow
involvement varies with types of primary tumors. The solid
tumors most frequently detected in bone marrow in adults are
carcinomas of the breast, prostate, lungs, and gastrointestinal
tract [3,4]. Angiosarcomas are rare, comprising only about
2% of all soft tissue sarcomas. Primary angiosarcomas can
occur at any site of the body. The most common sites are
the skin and superficial soft tissues, followed by the breast,
liver, spleen, and bone. Primary splenic angiosarcoma is an
uncommon primary tumor. Bone marrow metastasis in splenic
angiosarcoma, however, is exceedingly rare.
We report here the pathologic findings of a patient with
bone marrow metastasis of a primary unsuspected splenic
angiosarcoma.
Case Presentation
In December 2010, a 25-year-old woman complained of
anemic syndrome. She presented with serious normocytic
normochromic anemia with nodular splenomegaly. Bone
marrow biopsy was performed. Histopathological analysis
found regular bone trabeculae and delimiting medullary
compartments with normal cellular richness, where the 3
myeloid lineages were represented at different maturation
stages. There was a spindle proliferation delineating vascularlike
slits, which were sometimes empty or contained
erythrocytes. The cells presented moderate nuclear atypia,
often with a prominent acidophilic nucleolus.
The immunohistochemical study showed that spindle cells
expressed CD34 and did not express CD31. Results for CD117
(c-kit) were difficult to interpret (Figures 1 and 2).
The medullary location of a vascular-like spindle
proliferation was the most evident clue for diagnosis. Another
bone marrow biopsy was recommended to better pinpoint the
diagnosis. Informed consent was obtained.
In January 2011, a second bone marrow biopsy was
performed. Microscopic study highlighted, in the medullary
compartments, a spindle proliferation with marked vascular
differentiation. This was represented by slits or sometimes
large virtual vascular cavities, surrounded and partitioned by
turgescent endothelial cells. Islets of residual hematopoiesis
were identified; they consisted of elements belonging to the 3
myeloid lineages.
The new immunohistochemical study showed the same
profile. The spindle cells did not express c-kit (CD117), with
a positive internal control.
The diagnosis of medullary location of vascular kaposiform
proliferation was confirmed. Further immunostaining with
HHV8 was performed and was negative (Figure 3). HIV
serology and splenectomy were discussed.
Figure 1. Bone marrow biopsy: “bloody” appearance with
spindle cells proliferation, some cytologic atypia, and mitotic
activity.
Figure 2. Immunohistochemestry: CD34 (+), CD31 (-),
HHV8 (-).
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Anoun S, et al: Primary Splenic Angiosarcoma
angiosarcomas arising in the spleen have a unique propensity
for bone marrow metastasis, but this is unfortunately not well
documented in the literature [8]. We have found 3 cases in
the literature in which primary splenic angiosarcoma was
extended to the bone marrow.
The KI-67 proliferation index determines prognosis.
Because splenic angiosarcoma is a rare tumor, no specific
regimen of chemotherapy has been employed in enough cases
to enable the drawing of a conclusion as to effects on survival
[6].
Despite best efforts, the prognosis for this diagnosis is poor,
with mean survival ranging from 10.3 to 14.4 months [9].
Conclusion
Figure 3. Microscopy: spindle proliferation with marked
vascular differentiation. Nuclear atypia, with very few atypical
cells and some calcifications.
An abdominal computed tomography scan showed an
enlarged spleen with heterogeneous lesions. Splenectomy
was done in February 2011. The spleen weighed 706 g and
measured 21x14x8 cm. The outer surface was smooth. When
cut, multiple whitish nodules measuring between 0.4 and 1
cm in diameter were seen. The splenic parenchyma was the
site of saffron-colored deposits. At the hilum, 15 lymph nodes
were isolated, measuring between 4 and 12 mm in diameter.
Histological examination showed that the nodules described
above corresponded to a spindle proliferation with marked
vascular differentiation. Cells were sometimes epithelioidlike,
presenting moderate to marked nuclear atypia, with
very few atypical cells and budding nuclei, estimated at 10
mitoses per 10 fields at high magnification. Vascular slits were
engorged by erythrocytes
Moreover, there were calcifications with giant cells and a
small focus of necrosis.
Fourteen lymph nodes among the 15 examined were
metastatic.
The final diagnosis was that of a well-differentiated
angiosarcoma (grade II) of the spleen with lymph node
metastases (14 N+ of 15).
The patient received a chemotherapy course. Unfortunately,
the patient died 1 year after the splenectomy from metastasis.
Discussion and Review of the Literature
Primary splenic angiosarcoma is the most common
malignant non-hematopoietic tumor of the spleen [5]. These
tumors are rare, highly aggressive, and lethal. Metastases tend
to occur early and spread widely [6]. Metastatic diseases were
found in 69% of the patients in a reported series [7]. Early
metastasis from splenic angiosarcoma largely contributes to its
poor prognosis. Up to 86% of patients have distant metastases
at the time of presentation. Bone marrow metastasis, however,
is exceptionally rare. Interestingly, Wang et al. suggested that
We believe that the true incidence of bone marrow
metastasis is underreported. Bone marrow aspiration and
biopsy should be systematically performed in angiosarcoma
patients, especially when hematological abnormalities are
found on blood count.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
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9. Varma N, Vaiphei K, Varma S. Angiosarcoma presenting
with leucoerythroblastic anaemia bone marrow fibrosis and
massive splenomegaly. Br J Haematol 2000;110:503.
410

Case Report
DOI: 10.4274/tjh.2013.0119
Aplastic Anemia Associated with Oral Terbinafine: A Case
Report and Review of the Literature
Oral Terbinafin İlişkili Aplastik Anemi: Bir Olgu Sunumu ve
Literatür Derlemesi
Bülent Kantarcıoğlu1, Hüseyin Kemal Türköz2, Güven Yılmaz3, Funda Pepedil Tanrıkulu3,
Işık Kaygusuz Atagündüz3, Cafer Adıgüzel3, Tülin Fıratlı Tuğlular3
1Okmeydanı Training and Research Hospital, Clinic of Hematology, İstanbul, Turkey
2Marmara University Faculty of Medicine, Department of Pathology, İstanbul, Turkey
3Marmara University Faculty of Medicine, Department of Hematology, İstanbul, Turkey
Abstract:
Onychomycosis (OM) is a common fungal infection of the toenails and/or fingernails that is highly prevalent in the
general population and also responsible for significant morbidity. OM is caused by dermatophytes, nondermatophytic
molds, or yeast. Today systemic antifungal agents are considered as the gold standard for all types of OM. Here we
report a case of aplastic anemia associated with oral terbinafine use and a review of the literature on hematological
toxicities associated with terbinafine.
Key Words: Onychomycosis, Terbinafine, Aplastic anemia, Hematological toxicity, Pancytopenia, Adverse events
Özet:
Onikomikoz (OM) el ve ayak tırnaklarının sık görülen fungal enfeksiyonudur. Genel toplumda prevalansı yüksek bir
hastalık olması nedeniyle önemli morbiditeye yol açmaktadır. OM dermatofitler, nondermatofitik küf mantarları veya
mayalar ile ortaya çıkan hastalıklardır. Günümüzde onikomikozun tedavisinde sistemik antifungal ajanlar tüm OM
tiplerinde altın standart tedavi olarak kabul edilmektedir. Biz burada, oral terbinafin kullanımı sırasında gelişen bir
aplastik anemi olgumuzu ve literatürde terbinafine ile ilişkilendirilmiş olan hematolojik toksisitelerin derlemesini
sunuyoruz.
Anahtar Sözcükler: Onikomikoz, Aplastik anemi, Terbinafin, Hematolojik toksisite, Pansitopeni, Yan etkiler
Introduction
Onychomycosis is a very frequent fungal nail infection.
The prevalence can be as high as 28%-40%, especially in
elderly populations. Terbinafine is an antifungal agent
with both fungicidal and fungistatic properties, which is
highly effective and is the most frequently used agent in
onychomycosis. Oral terbinafine is generally well tolerated
with minimal reports of serious drug reactions. These rare
adverse events are mostly reported as case presentations, and
it is important to be familiar with them in order to be able
to evaluate the risk and inform patients accordingly [1,2,3].
Here we report a case of aplastic anemia (AA) associated
with oral terbinafine use and a review of the literature
on hematological toxicities associated with terbinafine.
Written informed consent was obtained from the patient
and her husband for publication of this manuscript and
accompanying images.
Address for Correspondence: Bülent KANTARCIOĞLU, M.D.,
Okmeydanı Training and Research Hospital, Clinic of Hematology, İstanbul, Turkey
Phone: +90 532 547 62 08 E-mail: bulentkantarcioglu@gmail.com
Received/Geliş tarihi : April 7, 2013
Accepted/Kabul tarihi : May 14, 2013
411

Turk J Hematol 2014;31:411-416
Kantarcıoğlu B, et al: Aplastic Anemia and Terbinafine
Case Presentation
A 41-year-old female presented with malaise, severe
fatigue, nausea, and vaginal bleeding in April 2011. In her
past history she was healthy, except that she reported taking
terbinafine pills for 8 weeks for the treatment of longstanding
recurrent toenail onychomycosis. She did not report any
immune reactions or allergies to any drugs or substances. Her
previous gynecological examination was normal, with a normal
β-human chorionic gonadotropin level. Her complete blood
count (CBC) revealed pancytopenia with white blood cell
count of 3.2x109/L, absolute neutrophil count of 0.8x10 9 /L,
hemoglobin of 7.4 g/dL, and platelet count of 34x10 9 /L. Her
physical examination was unremarkable with no evidence of
lymphadenopathy or organomegaly, except for a few petechiae
and ecchymoses on bilateral legs. Peripheral blood smear was
consistent with pancytopenia. Reticulocyte count was 0.7.
Liver enzymes were elevated [AST: 61 U/L (N: 10-37 U/L),
ALT: 117 U/L (N: 10-40 U/L), ALP: 434 U/L (N: 0-270 U/L),
GGT: 471 U/L (N: 7-49 U/L)]. Renal function tests and lactate
dehydrogenase were normal. Bone marrow aspiration and
biopsy revealed severe reduction of all cell lineages without
evidence of neoplastic infiltration, dysplasia, or fibrosis.
The counted cellularity was 5% in bone marrow. Bone
marrow karyotype analysis was normal. A gastroenterology
consultation performed for the liver enzyme abnormalities did
not provide an etiologic factor, pointing toward drug-induced
hepatitis. Further work-ups, including levels of vitamin B12
and folate; neck, chest, and abdominopelvic computerized
tomography; serology and polymerase chain reaction (PCR)
tests for viral hepatitis, human immunodeficiency, Epstein-Barr
virus, parvovirus B19, and cytomegalovirus; FLAER test for
paroxysmal nocturnal hemoglobinuria; antinuclear antibody
test; HLA-DRB1*15; and quantiferon test for tuberculosis,
were all negative. The patient was diagnosed with AA,
which was not severe at that time. Terbinafine treatment was
stopped. Due to the use of a drug with probable hematologic
toxicity, follow-up with supportive care was planned for the
patient. During 3-4 weeks of follow-up time, blood values
worsened with the need for erythrocyte and thrombocyte
transfusions, in accordance with very severe AA (SAA). She
did not have a matched related donor for transplantation.
After confirming the diagnosis with a second bone marrow
biopsy, she received rabbit antithymocyte globulin (ATG) plus
cyclosporine-A (CYC). The clinical outcome after ATG + CYC
was poor due to transient worsening of hematopoiesis and
infectious complications. She spent 3 months in the hospital
with perianal abscess, invasive aspergillosis, zoster virus
reactivation, and several catheter infections. She required
physical and psychological rehabilitation. Fortunately, the
blood values began to recover at the end of the fourth month
and full hematologic recovery was achieved at the end of the
sixth month. The patient is still in complete remission after 18
months of ATG + CYC treatment (Figures 1 and 2).
Discussion and Review of the Literature
Onychomycosis refers to all fungal infections of the nails.
It is difficult to cure, has high recurrence rates, and can
significantly affect a patient’s quality of life. Topical therapies
are generally ineffective, and today treatment with systemic
antifungal agents is accepted as the gold standard method for
onychomycosis. In clinical trials, continuous terbinafine has
repeatedly demonstrated higher efficacy when compared to
other antifungal treatments. The recommended dosage for the
treatment of onychomycosis is 250 mg/day orally for 12 weeks
for toenails and 6 weeks for fingernails [1,2,3].
Oral terbinafine is generally well tolerated with minimal
reports of serious drug reactions. Two large-scale postmarketing
surveillance studies showed that the incidence of serious
Figure 1. Bone marrow trephine biopsy: low cellularity in the
bone marrow consistent with aplastic anemia (H&E, 20x).
Figure 2. Bone marrow trephine biopsy: a few hematopoietic
cells intermixed with lymphocytes and plasmocytes in
interstitial areas (H&E, 100x).
412

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Turk J Hematol 2014;31:411-416
Table 1. Reported cases of terbinafine-associated hematological toxicity in the literature.
Reference
Number
Age
(years)/
Sex
Duration of
Terbinafine
Treatment
Nadir of
Cytopenia
9 60/F 32 days WBC 1.2
Neu 0.00
Reported Symptoms Terbinafine
Dose
Mouth/tongue ulceration,
fever, myalgia, malaise
Management Reported
Outcome
250 mg/day Hospitalized, i.v. antibiotics,
G-CSF
Recovered
9 35/not
reported
34 days WBC 2.9 Mouth ulcers, cellulitis 250 mg/day Cephalexin Recovered
Neu 0.3
9 78/M 27 days WBC 2.4
Neu 0.9
Flu-like illness 250 mg/day No treatment reported Recovered
9 69/F 31 days WBC 2.18
Neu 0.3
Mouth/tongue ulceration,
250 mg/day No treatment reported Recovered
anorexia
9 44/F 35 days Neu 0.03 Mouth ulceration, fever,
chills, headache
250 mg/day Hospitalized, i.v. antibiotics Recovered
9 74/F 32 days WBC 1.5
Neu 0.5
None reported 250 mg/day Hospitalized, i.v.
Recovered
antibiotics,
G-CSF
9 79/F Not reported Not given; Septic shock 250 mg/day Hospitalized, i.v. antibiotics Died
agranulocytosis
reported
9 68/F 39 days WBC 1.9
Neu 0.04
None reported 250 mg/day No treatment reported Recovered
9 63/F 46 days Neu 0.14 None reported 250 mg/day G-CSF, one dose Recovered
9 61/F 27 days WBC 3.8
Neu 0.9
Mouth ulceration 250 mg/day No treatment reported Not yet
recovered
9 66/F 67 days WBC 2.2
Neu 0.04
Mouth ulceration, ageusia 250 mg/day None reported Recovered
9 73/F 46 days Neu 0.00 Mouth and tongue
ulceration, fever,
anorexia, candidiasis
250 mg/day Hospitalized, i.v.
antibiotics,
amphotericin, nystatin
Not yet
recovered
413

Turk J Hematol 2014;31:411-416
Kantarcıoğlu B, et al: Aplastic Anemia and Terbinafine
Table 1. Reported cases of terbinafine-associated hematological toxicity in the literature.
10 60/M 6 weeks WBC 1.6
Neu 0.11
Mouth ulceration, fever, cellulitis, sepsis
syndrome
Not reported Hospitalized, i.v.
Recovered
antibiotics,
G-CSF
11 55/F 4 weeks WBC 1.6
Neu 0.00
Fever, dehydration, sepsis syndrome 250 mg/day Hospitalized, i.v.
Recovered
antibiotics,
G-CSF
12 42/M 30 days WBC 3.5
Neu 0.34
Fever, tongue ulceration, 250 mg/day Hospitalized, i.v.
Recovered
antibiotics,
G-CSF
13 63/M 4 weeks WBC 1400
Neu not reported
Hct 24.6
Plt 68,000
Fever, gum bleeding Not reported Hospitalized, i.v.
Recovered
antibiotics,
G-CSF
14 15/M 4 weeks WBC 2900
Neu 0.00
Fever, sore throat 250 mg/day Oral penicillin, observation Recovered
15 53/F Not reported WBC 1.9
Neu 0.01
Fatigue 250 mg/day G-CSF Recovered
15 75/M 63 days WBC 500
Hb 13.5
Plt 99,000
Nausea, vomiting, diarrhea, fever, abdominal
250 mg/day Hospitalized, i.v. antibiotics Recovered
pain
16 53/F Not reported Plt 8000 Ecchymosis, buccal hematoma 250 mg/day Hospitalized, prednisolone
1.5 mg/kg/day
Recovered
17 53/F Not reported Plt 63,000 Epistaxis 250 mg/day Observation Recovered
Presented
case
41/F 8 weeks WBC 1.5
Neu 0.2
Hb 6.5
Plt 12,000
Rtc 0.1%
Malaise, fatigue, nausea, vaginal bleeding 250 mg/day Supportive care initially Not recovered
spontaneously,
recovery obtained
with
ATG + CYC
M: male, F: female, WBC: white blood cell, Neu: neutrophil, Hb: hemoglobin, Hct: hematocrit, Plt: platelet, Rtc: reticulocyte count.
414

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Turk J Hematol 2014;31:411-416
side effects was

Turk J Hematol 2014;31:411-416
Kantarcıoğlu B, et al: Aplastic Anemia and Terbinafine
13. Conjeevaram G, Vongthavaravat V, Sumner R, Koff RS.
Terbinafine-induced hepatitis and pancytopenia. Dig Dis Sci
2001;46:1714-1716.
14. Aguilar C, Mueller KK. Reversible agranulocytosis associated
with oral terbinafine in a pediatric patient. J Am Acad
Dermatol 2001;45:632-634.
15. Kovacs MJ, Alshammari S, Guenther L, Bourcier M. Neutropenia
and pancytopenia associated with oral terbinafine. J Am Acad
Dermatol 1994;31:806.
16. Tsai HH, Lee WR, Hu CH. Isolated thrombocytopenia
associated with oral terbinafine. Br J Dermatol 2002;147:627-
628.
17. Grunwald MH. Thrombocytopenia associated with oral
terbinafine. Int J Dermatol 1998;37:634.
18. Scheinberg P. Aplastic anemia: therapeutic updates in
immunosuppression and transplantation. Hematology
2012;2012:292-300.
19. Guinan EC. Diagnosis and management of aplastic anemia.
Hematology 2011;2011:76-81.
20. Calado RT, Garcia AB, Falcão RP. Decreased activity of the
multidrug resistance P-glycoprotein in acquired aplastic
anaemia: possible pathophysiologic implications. Br J
Haematol 1998;102:1157-1161.
21. Calado RT, Garcia AB, Gallo DA, Falcão RP. Reduced function
of the multidrug resistance P-glycoprotein in CD34+ cells of
patients with aplastic anaemia. Br J Haematol 2002;118:320-
326.
22. Mizuno K, Fukami T, Toyoda Y, Nakajima M, Yokoi T.
Terbinafine stimulates the pro-inflammatory responses in
human monocytic THP-1 cells through an ERK signaling
pathway. Life Sci 2010;87:537-544.
23. Mintzer DM, Billet SN, Chmielewski L. Drug-induced
hematologic syndromes. Adv Hematol 2009;2009:495863.
416

Letter to the Editor
DOI: 10.4274/tjh.2014.0150
Significant Differences in Thymic Index of Thalassemia
Major Patients
Talasemi Major Hastalarının Timik İndeksinde Anlamlı
Farklılık
Yeşim Oymak 1 , Bülent Güzel 2 , Hüseyin Gümüş 2 , Erdem Dağlıoğlu 3 , Ali Ayçiçek 2 , Ahmet Koç 2 ,
Derya Özyürük 4
1 Dr. Behçet Uz Children’s Hospital, Clinic of Hematology, İzmir, Turkey
2 Harran University Faculty of Medicine, Department of Pediatric Hematology, Şanlıurfa, Turkey
3 Harran University Faculty of Medicine, Department of Radiology, Şanlıurfa, Turkey
4 Şanlıurfa Children’s Hospital, Clinic of Pediatric Hematology Oncology, Şanlıurfa, Turkey
To the Editor,
The thymus can be detected by ultrasonography until
the pre-adolescent period. After the early teens, it begins to
decrease in size [1]. In thalassemia patients, all organs have the
risk of organ dysfunction because of iron overload. Only a few
studies showed the size of the thymus in older children and
there were no studies in thalassemia patients [2,3]. The side
effects of iron overload in thalassemia major (TM) patients’
organs were examined through a literature search, but it
appears that the thymus has not been emphasized enough to
provide an adequate number of studies. The purpose of this
study was to determine whether the size of the thymus in
thalassemia patients differed from that in healthy children.
Sixty-five children with TM, aged 1 to 19 years, who had
been followed up in the pediatric hematology department at
Harran University were enrolled in the study between 1 July
and 31 July 2012. Fort-three TM patients and healthy siblings
of patients with another diagnosis were enrolled as a control
group because there was no literature related to the normal
range of thymus size for children older than 8 years.
The thymic size (thymic index) was calculated by multiplying
the largest transverse diameter by the largest longitudinal
diameter, measured in millimeters by ultrasonography (Toshiba
Corporation Medical System Division, Tokyo, Japan, type SSA
240 A with a 7.5-MHz linear probe) [4]. Ultrasonography was
Figure 1. Dot plot of thymic index among children with TM
(□—.) and healthy controls (○ ----) at various ages.
performed by the same radiologist. The average ferritin levels
for the last 6 months were recorded.
The study was approved by the Ethics Committee of
Harran University. The differences between groups were tested
with Mann-Whitney U tests. Correlations were evaluated with
Spearman’s test.
Address for Correspondence: Yeşim OYMAK, M.D.,
Dr. Behçet Uz Children’s Hospital, Clinic of Hematology, İzmir, Turkey
Gsm: +90 532 355 42 28 E-mail: yesimoymak@hotmail.com
Received/Geliş tarihi : April 11, 2014
Accepted/Kabul tarihi : June 24, 2014
417

Turk J Hematol 2014;31:417-419
Oymak Y, et al: Thymic Index and Thalassemia
The characteristics of the TM patients and the control
group are shown in Table 1. There were no differences in terms
of sex, age, weight, and height. However, the thymic index
of the TM patients was lower than that of the control group
(Figure 1).
The TM patients’ mean (± standard deviation) ferritin level
was 2967 (±1842) µg/mL. Ferritin level and thymic index did
not correlate (r=-0205, p=0.104). Seven (10.7%) TM patients
were splenectomized. The median (min-max) thymic index of
the splenectomized patients was 0.0 (0.0-304.0); it was 230.5
(0.0-903.0) in the non-splenectomized patients (p=0.001).
Splenectomized patients were older than non-splenectomized
patients (p=0.001).
In TM patients, the thymic index has not been previously
studied. Although corticosteroid effect was eliminated and
there were no differences in the age, sex, weight, and height,
the thymic index of the TM patients was lower than that of the
control group. Iron overload is the best-known harmful effect
of chronic transfusion on organs, and it might affect the thymus
as well. The size of the thymus is affected by several factors
like steroids, infections, and X-rays [5,6,7,8,9]. It has also been
found that thymus activity is related to thymus size [10]. In this
study, finding a difference in thymus size between TM patients
and controls supported the hypothesis that chronic transfusions
might affect the thymus; however, there were weaknesses in
the groups’ histories in terms of infection, malnutrition, and
having undergone X-rays. This is a preliminary study, and the
only difference that we knew about was that the groups were
receiving chronic blood transfusions, which might contribute
to decreased thymus size in TM patients. Zinc level, which is
known to be lower in TM patients, may affect the size of the
thymus, but there were no data available about the zinc levels
of our patients [8]. This study found no association between
the thymic index and ferritin level; however, each organ may
be affected to a different degree by the same ferritin level [11].
Smaller thymus sizes in splenectomized patients might depend
on their older ages.
Table 1. The characteristics of the TM patients and the
control group.
TM patients
n=65
Control group
n=43
Age (years) a 6.91 (1.00-19.00) † 7.04 (1.00-15.40) †
Sex (male/female) 31/34 † 21/22 †
Weight (kg) a 22 (5-43) † 22 (9-56) †
Height (cm) a 126 (64.0-160) † 119 (80-170) †
Thymic index a
(mmxmm)
208 (0-903)*‡ 391 (0-1189)*‡
a Median (min-max), † p>0.05, *p=0.01. TM: Thalassemia major.
It was also shown that stress and aging caused thymic
involution, which might protect the organism from the danger
of autoimmune diseases [12]. In one study it was shown that
thymus size declined with age in both children with atopic
dermatitis and healthy controls. However, the size of the
thymus among children with active atopic dermatitis was
higher compared to healthy controls [3]. Having a smaller
thymus may be an advantage for TM patients, who are prone to
alloimmunization related to transfusion.
In conclusion, thymic involution occurred more rapidly
in the TM group than in the normal controls. Further studies
that include other parameters, such as T2 magnetic resonance
imaging of the thymus for iron load and factors that may affect
thymus size, with bigger sample sizes are required to objectively
determine the effect of iron overload on thymic involution.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
Key Words: Thymus, Blood transfusion, Beta-thalassemia,
Iron overload, Tymic lndex
Anahtar Sözcükler: Timüs, Kan Transfüzyonu, Beta
talasemi, Demir yüklenmesi, Timik indeks
References
1. Aspinall R, Andrew D, Pido-Lopez J. Age-associated
changes in thymopoiesis. Springer Semin Immunopathol
2002;24:87-101.
2. Adam EJ, Ignotus PI. Sonography of the thymus in healthy
children: frequency of visualization, size, and appearance.
AJR Am J Roentgenol 1993;161:153-155.
3. Olesen AB, Andersen G, Jeppesen DL, Benn CS, Juul S,
Thestrup-Pedersen K. Thymus is enlarged in children with
current atopic dermatitis. A cross-sectional study. Acta Derm
Venereol 2005;85:240-243.
4. Yekeler E, Tambag A, Tunaci A, Genchellac H, Dursun
M, Gokcay G, Acunas G. Analysis of the thymus in 151
healthy infants from 0 to 2 years of age. J Ultrasound Med
2004;23:1321-1326.
5. Kolte L, Dreves AM, Ersbøll AK, Strandberg C, Jeppesen
DL, Nielsen JO, Ryder LP, Nielsen SD. Association between
larger thymic size and higher thymic output in human
immunodeficiency virus-infected patients receiving highly
active antiretroviral therapy. J Infect Dis 2002;185:1578-
1585.
6. Caffey J, Di Liberti C. Acute atrophy of the thymus induced
by adrenocorticosteroids: observed roentgenographically
in living infants: a preliminary report. Am J Roentgenol
1959;82:530-540.
7. Griffith SP, Levine QR, Kaber DH, Blumenthal S. Evaluation
of enlarged cardiothymic image in infancy: thymolytic effect
of steroid administration. Am J Cardiol 1961;8:311-318.
418

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Turk J Hematol 2014;31:417-419
8. Hasselbalch H, Jeppesen DL, Ersbøll AK, Lisse IM, Nielsen
MB. Sonographic measurement of thymic size in healthy
neonates. Relation to clinical variables. Acta Radiol
1997;38:95-98.
9. Mahyar A, Ayazi P, Pahlevan AA, Mojabi H, Sehhat MR,
Javadi A. Zinc and copper status in children with betathalassemia
major. Iran J Pediatr 2010;20:297-302.
10. Auwaerter PG, Kaneshima H, McCune JM, Wiegand G,
Griffin DE. Measles virus infection of thymic epithelium in
the SCID-hu mouse leads to thymocyte apoptosis. J Virol
1996;70:3734-3740.
11. Kolnagou A, Natsiopoulos K, Kleanthous M, Ioannou A,
Kontoghiorghes GJ. Liver iron and serum ferritin levels
are misleading for estimating cardiac, pancreatic, splenic
and total body iron load in thalassemia patients: factors
influencing the heterogenic distribution of excess storage
iron in organs as identified by MRI T2*. Toxicol Mech
Methods 2013;23:48-56.
12. Aronson M. Hypothesis: involution of the thymus with
aging--programmed and beneficial. Thymus 1991;18:7-13.
419

Letter to the Editor
DOI: 10.4274/tjh.2014.0081
c.761C>T Mutation Linked Hyper IgM Syndrome
Presenting with Hypertransaminasemia and Arthritis
Hipertransaminazemi ve Artrit ile Kendini Gösteren c.761C>T
Mutasyonuna Bağlı Hiper IgM Sendromu
Mehmet Halil Celiksoy 1 , Stephan Borte 2 , Aydan İkincioğulları 3 , Meltem Ceyhan Bilgici 4 , Filiz Karagöz 5 ,
Ayhan Gazi Kalaycı 6 , Alişan Yıldıran 3
1 Ondokuz Mayıs University Faculty of Medicine, Department of Pediatric Allergy and Immunology, Samsun, Turkey
2 Leipzig University Faculty of Medicine, Department of Clinical Immunolgy, Leipzig, Germany
3 Ankara University Faculty of Medicine, Department of Pediatric Allergy and Immunology, Ankara, Turkey
4 Ondokuz Mayıs University University Faculty of Medicine, Department of Pediatric Radiology, Samsun, Turkey
5 Ondokuz Mayıs University Faculty of Medicine, Department of Pathology, Samsun, Turkey
6 Ondokuz Mayıs University Faculty of Medicine, Department of Pediatric Gastroenterology, Hepatology and Nutrition, Samsun, Turkey
To the Editor,
Hyperimmunoglobulin M syndrome (HIGM) is a
primary immunodeficiency characterized with low IgG,
IgA, and IgE and normal or elevated IgM levels due to
a defect in class switching recombination [1]. In this
report, we present a patient with CD40 ligand (CD40L)
deficiency who had arthritis and hypertransaminasemia
with no history of serious infection until 8 years of age.
An 8-year-old male patient presented because of a
2-year history of knee swelling and pain. The patient had
no history of serious infection and he had been followed
for asthma and elevated transaminase level by the
Department of Pediatric Gastroenterology for the past 3
years. His parents were not relatives. Physical examination
revealed the following: both knees had tenderness,
swelling, redness, and limited range of motion. Other
systems were normal. Laboratory analysis revealed the Figure 1. a) There is c.761C>T mutation in the CD40 ligand gene. b)
following results: Hb: 11.7 g/dL, Hct: 37.7%, MCV: 71.7 MR cholangiography findings: dilated common choledochal (black
fL, leukocytes: 8.0x109/L, platelets:405x10 9 /L, CRP: 18 star) and intrahepatic bile ducts, narrowing of the bile ducts, and
irregularities at multiple levels (white arrows). c) Bile duct with
mg/L, ESR: 25 mm/h, ALT: 103 U/L (normal range: 0-55),
increasing concentric connective tissue in one portal tract (trichrome
AST: 63 U/L (5-40). The patient was negative for stain, 10x).
HBsAg, anti-HBs, anti-HCV, anti-CMV IgG, and CMV
immunoglobulins were as follows: IgG: 1.27 g/L (5.5-17),
by polymerase chain reaction (PCR), while he was
positive for anti-CMV IgM (252.7%, normal range: 90- IgA: 0.06 g/L (0.6-3.3), IgM: 5.09 g/L (0.6-2.7), IgE: 16 IU/
100). Isohemagglutinins were 1/512 positive. The serum mL. Examinations for arthritis did not reveal remarkable
Address for Correspondence: Mehmet Halil CELİKSOY, M.D.,
Ondokuz Mayıs University Faculty of Medicine, Department of Pediatric Allergy and Immunology, Samsun, Turkey
Phone: +90 362 312 19 19 E-mail: drmhc@hotmail.com
Received/Geliş tarihi : February 21, 2014
Accepted/Kabul tarihi : July 3, 2014
420

Celiksoy MH, et al: CD40L Deficiency and Hypertransaminasemia
Turk J Hematol 2014;31:420-421
results and no pathogen could be isolated. Flow cytometry
revealed CD40L deficiency, while analysis showed c.761C>T
mutation in the same gene (Figure 1a). The patient was
diagnosed with HIGM syndrome. A liver biopsy was done and
magnetic resonance (MR) cholangiography was conducted
for hypertransaminasemia. MR cholangiography and biopsy
specimen findings were consistent with sclerosing cholangitis
(Figures 1b and 1c). Informed consent was obtained.
In HIGM syndrome, clinical findings occur at early
ages and the mean age of diagnosis is less than 1 year.
Clinically, HIGM has similarities with recurring respiratory
tract infections causing bronchiectasis and other humoral
immune deficiencies presenting with sinus and ear infections
[2]. Recurrent respiratory infections were absent in our
case. Additionally, our patient was diagnosed with asthma.
Recurrent respiratory infections may be confused with asthma
attacks by physicians. Therefore, our patient could have been
diagnosed late.
Although other markers were negative, anti-CMV IgM
values were always high in this case. CMV-DNA PCR tests,
applied at intervals, were also negative. In HIGM syndrome,
the serum IgM level is normal or high but serum IgG and IgA
levels are low, because of a defect in isotype class switching
of B cells [3]. Furthermore, there is no response to protein
antigens, though some IgM anti-polysaccharide antibodies,
including isohemagglutinins, can be produced [2]. Therefore,
our patient had CMV IgM probably due to CMV infection.
However, he could not produce CMV IgG because of the
nature of his disease.
Our patient was being monitored due to
hypertransaminasemia in the gastroenterology outpatient
clinic. Abdominal ultrasonography showed no cholangiopathy,
but MR cholangiography findings were consistent with
sclerosing cholangitis. Portal fibrosis was seen in only 1 of 4
vena portae samples in his liver biopsy. The most common
characteristic finding of liver biopsy for sclerosing cholangitis
is interlobular and septal fibrosis of bile ducts known as ‘onion
skin’ [4]. Our findings of liver biopsy were not characteristic
for sclerosing cholangitis. When clinical and radiological
findings were evaluated together with liver biopsy results, the
patient was diagnosed with sclerosing cholangitis in an initial
state.
In conclusion, idiopathic arthritis and persistent
hypertransaminasemia should also be considered in the
differential diagnosis of primary immune deficiencies.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
Key Words: Humoral immune response, Immunodeficiency
diseases, Immune response disorder, Immunoglobulins, Hyper
IgM syndrome, CD40L
Anahtar Sözcükler: Hümoral immün yanıt, İmmün
yetmezlikler, İmmün yanıt bozukluğu, İmmünglobulinler,
Hiper IgM sendromu, CD40L
References
1. Lee WI, Torgerson TR, Schumacher MJ, Yel L, Zhu Q, Ochs
HD. Molecular analysis of a large cohort of patients with
the hyper immunoglobulin M (IgM) syndrome. Blood
2005;105:1881-1890.
2. Davies EG, Thrasher AJ. Update on the hyper immunoglobulin
M syndromes. Br J Haematol 2010;149:167-180.
3. Montella S, Maglione M, Giardino G, Di Giorgio A, Palamaro
L, Mirra V, Ursini MV, Salerno M, Pignata C, Caffarelli C,
Santamaria F. Hyper IgM syndrome presenting as chronic
suppurative lung disease. Ital J Pediatr 2012;38:45.
4. Farrell RJ, Kelly CP. Sclerosing cholangitis and recurrent
pyogenic cholangitis. In: Feldman M, Friedman LS, Sleisenger
MH (eds). Sleisenger & Fordtran’s Gastrointestinal and
Liver Disease: Pathophysiology, Diagnosis, Management,
Vol 2, 7th ed. Philadelphia, Saunders, 2002.
421

Letter to the Editor
DOI: 10.4274/tjh.2013.0404
Blastic Plasmacytoid Dendritic Cell Neoplasm:
Single-Center Experience with Two Cases in One Year
Blastik Plazmasitoid Dendritik Hücreli Neoplazi: Bir Yılda İki
Olguyu İçeren Tek Merkez Deneyimi
Alexandra Agapidou 1 , Sophia Vakalopoulou 1 , Dimitra Markala 2 , Christina Chadjiaggelidou 1 , Maria Tzimou 1 ,
Theodosia Papadopoulou 1 , Vasileia Garypidou 1
1 Aristotle University of Thessaloniki Faculty of Medicine, Hippokratio General Hospital, Second Propaedeutic Department of Internal Medicine,
Division of Hematology, Thessaloniki, Greece
2 Theagenion Cancer Hospital, Thessaloniki, Greece
To the Editor,
A 78-year-old Caucasian female patient presented
to our department with a cutaneous lesion on her right
shoulder (Figure 1a). Laboratory data disclosed mild anemia
(hemoglobin: 11.3 g/dL) thrombocytopenia (139x10 9 /L) and
30% morphologically immature atypical cells in the peripheral
blood. Bone marrow aspiration showed 5% infiltration of
immature blast cells with the following immunophenotype:
CD45 (+), CD123 (+), CD85k (+), CD33 (-), CD14 (-), CD16
(-), CD19 (-), CD5 (-), CD10 (-), CD20 (-), CD56 (+) 20%,
CD4 (+), NG2 (+). No chromosomal alterations were detected
by cytogenetic analysis of the bone marrow (46,XX). Specific
karyotypic aberrations were not found. She had axillary, jugular,
submandibular, and supraclavicular lymphadenopathy.
Cutaneous, lymph node, and bone marrow biopsy confirmed
the diagnosis of blastic plasmacytoid dendritic cell neoplasm
(BPDCN). She was treated with cyclophosphamide,
vincristine, adriamycin, and dexamethasone (Cy-VAD) as part
of an acute lymphoblastic leukemia treatment-protocol. She
achieved first complete remission. Due to the highly aggressive
type of leukemia, we decided to continue with induction 2
chemotherapy (etoposide-cytosine arabinoside), but she died
5 months after the first sign due to multiorgan failure.
One year later, a 75-year-old Caucasian male patient
presented with a generalized purplish skin rash from the
head to the lower extremities that expanded very rapidly
(Figure 1b and 1c). Laboratory data revealed anemia
(hemoglobin: 10.9 g/dL), thrombocytopenia (100x109/L), and
a b c
Figure 1. a) Skin lesion of Caucasian female patient, before
treatment. b) Skin lesions of Caucasian male patient before
treatment and c) after treatment (abdominal-lower genital
area).
42% morphologically immature atypical cells in the peripheral
blood. Bone marrow aspiration showed 88% infiltration of
immature blast cells with the following immunophenotype:
CD45 (+) low, CD43 (+), CD123 (+), CD56 (+), CD4 (+),
CD34 (-). Computed tomography scans did not disclose
pathologic lymphadenopathy. Histopathology of skin lesions
showed blast cell infiltrate. Immunohistochemical analysis
confirmed the presence of cells with the aforementioned
immunophenotypic features. A basic immunophenotype with
CD4 (+), CD56 (+), CD123 (+), and negative T, B, and NK
cells led to the diagnosis of BPDCN as per the current WHO
classification [1]. In the cytogenetic analysis, a pathologic
karyotype was found (46,XY, del (12), (p12), del (17), (p11)
[17]/46,XY [13]). He began acute myeloid leukemia-type
chemotherapy with idarubicin and arabinoside-c and he
achieved complete remission after induction. We changed
his treatment plans and continued with CHOP due to his
poor performance status, and, after 4 cycles, he still remains
Address for Correspondence: Alexandra AGAPIDOU, M.D.,
Aristotle University of Thessaloniki Faculty of Medicine, Hippokratio General Hospital, Second Propaedeutic Department of Internal Medicine, Division of Hematology, Thessaloniki, Greece
Phone: +30 694 880 97 42 E-mail: alekagapidou@yahoo.gr
Received/Geliş tarihi : December 2, 2013
Accepted/Kabul tarihi : January 14, 2014
422

Agapidou A, et al: Blastic Plasmacytoid Dendritic Cell Neoplasm
Turk J Hematol 2014;31:422-423
without clinical signs. Informed consent was obtained.
Plasmacytoid dendritic cells were first identified 50
years ago by Lennert and his associates [2]. BPDCN is a
rare, highly aggressive hematopoietic malignancy that is
characterized by cutaneous infiltration with or without
bone marrow involvement. Its overall incidence is extremely
low. The leukemic form of the disease is very rare. BPDCN
predominantly affects males, and generally the elderly [3].
The majority of patients present with asymptomatic solitary
or multiple cutaneous reddish-brown nodules. Clinically, this
malignancy generally presents in the skin, often followed by
bone marrow and blood involvement. However, any organ can
be affected. The disease follows a short course and fulminant
leukemia is the common terminal stage. Diagnosis is based
on the expression of CD4, CD56, and CD123 in the absence
of T-cell, B-cell, or myeloid markers. Although identification
of the immunophenotypic features of BPDCN has improved
its recognition, this entity remains diagnostically challenging.
Insufficient knowledge of this entity and inadequate
immunophenotypic investigation can lead to the misdiagnosis
of a different leukemia. The prognosis of patients with BPDCN
is poor, with a median survival of 12 months regardless of
treatment type. Acute lymphoblastic leukemia-type treatment
regimens are advised and a promising initial response may
occur, but this is followed by quick relapse [4]. There is also
the option of bone marrow transplantation for young patients
with an acceptable performance status.
In conclusion, we encountered a rare type of leukemia. The
rarity of this disease does not enable prospective clinical trials
to identify a better therapeutic strategy, which, at present, is
based on clinicians’ experience and on cooperation among
them.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
Key Words: Plasmacytoid dendritic cell, Leukemia,
Cutaneous lesion, CD4 (+), CD56 (+)
Anahtar Sözcükler: Plazmasitoid Dendritik Hücre,
Lösemi, Deri Lezyonu, CD4 (+), CD56 (+)
References
1. Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein
H, Thiele J, Vardiman JW. WHO Classification of Tumours
of Haematopoietic and Lymphoid Tissues, 4th ed. Lyon,
France, International Agency for Research on Cancer, 2008.
2. Marafioti T, Paterson JC, Ballabio E, Reichard KK, Tedoldi
S, Hollowood K, Dictor M, Hansmann ML, Pileri SA, Dyer
MJ, Sozzani S, Dikic I, Shaw AS, Petrella T, Stein H, Isaacson
PG, Facchetti F, Mason DY. Novel markers of normal and
neoplastic human plasmacytoid dendritic cells. Blood
2008;111:3778-3792.
3. Pagano L, Valentini CG, Pulsoni A, Fisogni S, Carluccio P,
Mannelli F, Lunghi M, Pica G, Onida F, Cattaneo C, Piccaluga
PP, Di Bona E, Todisco E, Musto P, Spadea A, D’Arco A,
Pileri S, Leone G, Amadori S, Facchetti F; GIMEMA-ALWP
(Gruppo Italiano Malattie Ematologiche dell’Adulto, Acute
Leukemia Working Party). Blastic plasmacytoid dendritic
cell neoplasm with leukemic presentation: an Italian
multicenter study. Haematologica 2013;98:239-246.
4. Pinto-Almeida T, Fernandes L, Sanches M, Lau C, Lima M,
Alves R, Selores M. A case of blastic plasmacytoid dendritic
cell neoplasm. Ann Dermatol 2012;24:235-237.
423

Letter to the Editor
DOI: 10.4274/tjh.2014.0166
Mogamulizumab Treatment in a Hemodialysis Patient
with Adult T-Cell Leukemia/Lymphoma
Erişkin T-hücreli Lösemi/Lenfomalı Hemodiyaliz Hastasında
Mogamulizumab Tedavisi
Mari Yoshihara 1 , Yasushi Kubota 1,2 , Makoto Fukuda 3 , Tomoya Kishi 3 , Yuji Ikeda 3 , Shinya Kimura 1
1 Saga University Faculty of Medicine, Department of Internal Medicine, Division of Hematology Respiratory Medicine, and Oncology, Saga, Japan
2 Saga University Faculty of Medicine Hospital, Department of Transfusion Medicine, Saga, Japan
3 Saga University Faculty of Medicine, Department of Internal Medicine, Division of Nephrology, Saga, Japan
To the Editor,
Here we describe, for the first time, a hemodialysis patient
suffering from adult T-cell leukemia/lymphoma (ATL) who
was treated with mogamulizumab, a defucosylated anti-CC
chemokine receptor 4 (CCR4) monoclonal antibody [1].
An 83-year-old female was admitted to the hospital suffering
from fatigue, leukocytosis, and hypercalcemia. On admission,
laboratory tests revealed that her leukocyte count was elevated
to 76x109/L (>80% abnormal lymphocytes). Blood chemistry
analysis revealed elevated lactate dehydrogenase (LDH: 808
IU/L) and soluble interleukin-2 receptor (sIL-2R: 43.465 U/
mL). Seropositivity for human T-cell leukemia virus type-1
(HTLV-1) was confirmed and monoclonal integration of HTLV-
1 was detected by Southern blotting of DNA isolated from
peripheral blood (PB). She was diagnosed with acute ATL.
Flow cytometric analysis demonstrated that the abnormal
lymphocytes were CD3+CD4+CD25+. Computed tomography
(CT) revealed multiple lymphadenopathies, involving the
supraclavicular fossae and the inguinal, mediastinum, and
para-aortic regions.
She was treated with systemic chemotherapy (THP-
COP regimen: cyclophosphamide, pirarubicin, vincristine,
and prednisolone) on day 8 post-admission. Although the
number of ATL cells in the PB gradually decreased, they
were persistent. On day 18 of THP-COP, she experienced
a high fever and hypotension. Because serum β-D-glucan
levels were elevated and a chest CT revealed a pulmonary
infiltrate, she was administered cefepime and voriconazole.
However, she developed anuric acute renal failure, probably
induced by voriconazole, and so emergent hemodialysis
was initiated. Subsequently, both the number of ATL cells
Figure 1. Clinical course: time-points of THP-COP
(cyclophosphamide, pirarubicin, vincristine, and prednisolone)
and mogamulizumab administration. WBC counts, ATL cell
counts, and LDH and creatinine levels throughout the clinical
course, and the concentration of mogamulizumab in the
plasma pre- and post-dialysis, are shown. CHDF: Continuous
hemodiafiltration, HD: hemodialysis.
and her LDH levels increased, suggesting that the THP-COP
regimen was not working. Because the ATL cells expressed
high levels of CCR4, she received an intravenous infusion of
mogamulizumab (1.0 mg/kg) once a week for 8 weeks. The
concentration of mogamulizumab in the plasma was measured
using an enzyme-linked immunosorbent assay [2,3]. The
plasma concentrations of mogamulizumab before and after
hemodialysis during the first mogamulizumab infusion and
Address for Correspondence: Yasushi Kubota, M.D.,
Saga University Faculty of Medicine, Department of Internal Medicine, Division of Hematology Respiratory Medicine, and Oncology, Saga, Japan
Phone: +81-952-34-2366 E-mail: kubotay@cc.saga-u.ac.jp
Received/Geliş tarihi : April 24, 2014
Accepted/Kabul tarihi : August 12, 2014
424

Yoshihara M, et al: Mogamulizumab in a Hemodialysis Patient with ATL Turk J Hematol 2014;31:424-425
just before the second infusion (Ctrough) were 14,104.8 ng/mL,
16,092.2 ng/mL, and 5901.2 ng/mL, respectively. The plasma
levels of mogamulizumab before and after hemodialysis were
comparable, and Ctrough was in the range of published data
[2], suggesting that therapeutic levels of mogamulizumab may
be maintained in patients undergoing dialysis (Figure 1). Five
months after the mogamulizumab treatment the leukemia
relapsed. However, the patient did not accept any further
treatment or a rechallenge with mogamulizumab. She was
managed with best supportive care, and she died 10 months
after diagnosis with ATL.
ATL is an aggressive peripheral T-cell neoplasm that
cannot usually be cured by conventional chemotherapy [4,5].
Allogeneic hematopoietic stem cell transplantation is now
considered the only curable treatment for young patients with
ATL, but it is not applied to elderly patients because of higher
toxicities. Currently, chemotherapy is the only therapeutic
option for elderly ATL patients but there are concers about
their safety and efficacy [6]. Mogamulizumab is a humanized
anti-CCR4 antibody with a defucosylated Fc region and has
been used to treat relapsed/refractory CCR4-positive ATL with
50% efficacy in a phase II study [3,7]. The fucose content in the
oligosaccharide structure in the Fc region of mogamulizumab
is reduced using Potelligent technology, which enhances the
antibody-dependent cellular toxicity because of increased
binding affinity to the Fcγ receptor on effector cells [8]. More
recently, mogamulizumab was also approved for the treatment
of relapsed CCR4-positive peripheral T-cell lymphoma and
cutaneous T-cell lymphoma in Japan [9].
To date, limited data exist about the application of
mogamulizumab in patients undergoing hemodialysis. Here,
mogamulizumab treatment resulted in complete remission
of an elderly ATL patient with no major adverse events such
as infusion reaction or skin rash (including re-exacerbation
of renal function). Thus, administration of mogamulizumab
may be considered as a safe therapeutic option in this setting.
The present case shows that therapeutic mogamulizumab
levels can be achieved and maintained in patients undergoing
hemodialysis as mogamulizumab is not eliminated by the
procedure.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
Key Words: Adult T-cell leukemia/lymphoma,
Mogamulizumab, Hemodialysis, CCR4, HTLV-1
Anahtar Sözcükler: Erişkin T-hücreli lösemi/lenfoma,
Mogamulizumab, Hemodiyaliz, CCR4, HTLV-1
References
1. Ishida T, Utsunomiya A, Inagaki A, Yano H, Komatsu H,
Iida S, Imada K, Uchiyama T, Akinaga S, Shitara K, Ueda R.
Defucosylated humanized anti-CCR4 monoclonal antibody
KW-0761 as a novel immunotherapeutic agent for adult
T-cell leukemia/lymphoma. Clin Cancer Res 2010;16:1520-
1531.
2. Yamamoto K, Utsunomiya A, Tobinai K, Tsukasaki K, Uike
N, Uozumi K, Yamaguchi K, Yamada Y, Hanada S, Tamura
K, Nakamura S, Inagaki H, Ohshima K, Kiyoi H, Ishida T,
Matsushima K, Akinaga S, Ogura M, Tomonaga M, Ueda
R. Phase I study of KW-0761, a defucosylated humanized
anti-CCR4 antibody, in relapsed patients with adult T-cell
leukemia-lymphoma and peripheral T-cell lymphoma. J
Clin Oncol 2010;28:1591-1598.
3. Ishida T, Joh T, Uike N, Yamamoto K, Utsunomiya A,
Yoshida S, Saburi Y, Miyamoto T, Takemoto S, Suzushima
H, Tsukasaki K, Nosaka K, Fujiwara H, Ishitsuka K, Inagaki
H, Ogura M, Akinaga S, Tomonaga M, Tobinai K, Ueda R.
Defucosylated anti-CCR4 monoclonal antibody (KW-0761)
for relapsed adult T-cell leukemia-lymphoma: a multicenter
phase II study. J Clin Oncol 2012;30:837-842.
4. Uchiyama T, Yodoi J, Sagawa K, Takatsuki K, Uchino H.
Adult T-cell leukemia: clinical and hematologic features of
16 cases. Blood 1977;50:481-492.
5. Tsukasaki K, Hermine O, Bazarbachi A, Ratner L, Ramos
JC, Harrington W Jr, O’Mahony D, Janik JE, Bittencourt
AL, Taylor GP, Yamaguchi K, Utsunomiya A, Tobinai K,
Watanabe T. Definition, prognostic factors, treatment, and
response criteria of adult T-cell leukemia-lymphoma: a
proposal from an international consensus meeting. J Clin
Oncol 2009;27:453-459.
6. Fukushima N, Itamura H, Urata C, Tanaka M, Hisatomi T,
Kubota Y, Sueoka E, Kimura S. Clinical presentation and
outcome in patients of over 75 years old with malignant
lymphoma. International Journal of Clinical Medicine
2011;2:246-253.
7. Ito A, Ishida T, Yano H, Inagaki A, Suzuki S, Sato F,
Takino H, Mori F, Ri M, Kusumoto S, Komatsu H, Iida S,
Inagaki H, Ueda R. Defucosylated anti-CCR4 monoclonal
antibody exercises potent ADCC-mediated antitumor effect
in the novel tumor-bearing humanized NOD/Shi-scid,
IL-2Rγ null mouse model. Cancer Immunol Immunother
2009;58:1195-1206.
8. Niwa R, Shoji-Hosaka E, Sakurada M, Shinkawa T, Uchida
K, Nakamura K, Matsushima K, Ueda R, Hanai N, Shitara K.
Defucosylated chimeric anti-CC chemokine receptor 4 IgG1
with enhanced antibody-dependent cellular cytotoxicity
shows potent therapeutic activity to T-cell leukemia and
lymphoma. Cancer Res 2004;64:2127-2133.
9. Ogura M, Ishida T, Hatake K, aniwaki M, Ando K, Tobinai
K, Fujimoto K, Yamamoto K, Miyamoto T, Uike N, Tanimoto
M, Tsukasaki K, Ishizawa K, Suzumiya J, Inagaki H, Tamura
K, Akinaga S, Tomonaga M, Ueda R. Multicenter phase II
study of mogamulizumab (KW-0761), a defucosylated
anti-cc chemokine receptor 4 antibody, in patients with
relapsed peripheral T-cell lymphoma and cutaneous T-cell
lymphoma. J Clin Oncol 2014;32:1157-1163.
425

Letter to the Editor
DOI: 10.4274/tjh.2014.0049
Chediak-Higashi Syndrome: A Case Report of a Girl
Without Silvery Hair and Oculocutaneous Albinism
Presenting with Hemophagocytic Lymphohistiocytosis
Chediak-Higashi Sendromu: Gri Saç ve Okülokütanöz
Albinizm Olmaksızın Hemofagositik Lenfohistiositoz ile
Başvuran Bir Kız Çocuğu Olgu Sunumu
Murat Elevli 1 , Halil Uğur Hatipoğlu 2 , Mahmut Civilibal 2 , Nilgün Selçuk Duru 2 , Tiraje Celkan 3
1 Sakarya University Faculty of Medicine, Clinic of Pediatrics, Sakarya, Turkey
2 Haseki Education and Research Hospital, Clinic of Pediatrics, İstanbul, Turkey
3 İstanbul University Cerrahpaşa Faculty of Medicine, Department of Pediatric Hematology-Oncology, İstanbul, Turkey
To the Editor,
Chediak-Higashi syndrome (CHS) is a rare, autosomal
recessive inherited disorder characterized by variable degrees
of oculocutaneous albinism, severe immune deficiency
and unassociated lymphoproliferative syndrome, and
intracytoplasmic giant granules in leukocytes, monocytes,
platelets, melanocytes, and erythroid precursors [1,2,3,4,5].
CHS is caused by mutations in the lysosomal trafficking
regulator gene (LYST) [3,6]. The role of the LYST gene in the
trafficking of granules results in defective release of melanin
or cytolytic enzymes, causing hypopigmentation of the skin
and hair as well as cytotoxic defect [3]. There are 2 clinical
periods of the disease: stable and accelerated. In the accelerated
phase, fever, hepatosplenomegaly, hepatitis, lymphohistiocytic
infiltration, pancytopenia, coagulopathy, hemorrhage, and
peripheral neuropathy are seen [1]. Herein, we report a case
of CHS presented with hemophagocytic lymphohistiocytosis
(HLH).
A 5-month-old girl presented with fever. She was febrile and
pale, and she had splenomegaly with no hepatomegaly. There
were no neurological symptoms, lymphadenopathy, or bleeding
signs. Her body temperature was over 38.8 °C for 8 days in spite
of ampicillin/sulbactam and netilmicin therapy. Hematological
investigation revealed hemoglobin of 6.3 g/dL, white blood cell
count of 3.8x109/L (70% lymphocytes, 10% neutrophils), and
Figure 1. A. Hemophagocytosis on bone marrow smear.
B. An intracytoplasmic giant granule in a monocyte on
peripheral blood smear.
C. Light microscopic image of the hair shaft shows abnormal
clumping of melanin in patient’s hair. Pigment clumbs are
small and uniformly and regularly distributed along the hair
shaft. This is consistant with Chediak-Higashi syndrome.
D. Our patient does not have oculocutaneous albinism and
she is black-haired.
Address for Correspondence: Halil Uğur HATİPOĞLU, M.D.,
Haseki Education and Research Hospital, Clinic of Pediatrics, İstanbul, Turkey
Gsm: +90 532 680 67 65 E-mail: huhatipoglu@gmail.com
Received/Geliş tarihi : February 2, 2014
Accepted/Kabul tarihi : May 13, 2014
426

Elevli M, et al: Chediak-Higashi Syndrome Presented with Hemophagocytic Lymphohistiocytosis
Turk J Hematol 2014;31:426-427
platelet count of 84x10 9 /L. Erythrocyte sedimentation rate was
25 mm/h, C reactive protein was 6.75 mg/dL, and ferritin was
635 ng/mL, with a normal fibrinogen level. Serum triglyceride
level was 584 mg/dL with a normal serum cholesterol level.
Serum lactate dehydrogenase, serum glutamic oxaloacetic
transaminase, and serum glutamic pyruvate transaminase
levels were 882 U/L, 254 U/L, and 54 U/L, respectively.
Her fever was controlled with piperacillin/tazobactam and
amikacin combined with fluconazole. Serological markers
were negative for cytomegalovirus, Epstein-Barr virus, human
immunodeficiency virus, parvovirus, Toxoplasma, rubella, and
hepatitis B virus. Salmonella and Brucella tube agglutination
test results were also negative. Blood and urine cultures did
not demonstrate any infectious agents. Tandem MS, blood
amino acid levels, urinary organic acid profile, and urinary
mucopolysaccharide screening tests were all normal. On bone
marrow aspiration smear, hemophagocytosis was observed.
The patient was diagnosed with HLH and the HLH-2004
treatment protocol, including dexamethasone and etoposide,
was administrated. No gene defect was determined on exons 2
and 3 of the perforin 1 coding region. On both bone marrow
aspiration and peripheral blood smears, intracytoplasmic giant
granules in lymphocytes and monocytes were observed. Hair
analysis for CHS was consistent with CHS. At the end of the
initial therapy, the disease was in remission. Continuation
therapy of the HLH regimen was then started. Stem cell
transplantation (SCT) has been planned. As there was no
matched related donor for SCT at that time, we will be treating
her according to HLH-2004 continuation therapy until a
matched or mismatched unrelated donor is found. Informed
consent was obtained.
Our patient was diagnosed with HLH because there
was hemophagocytosis on bone marrow aspiration (Figure
1a) and she had splenomegaly, fever, pancytopenia,
hypertriglyceridemia, and high ferritin levels. Sometimes the
CHS diagnosis can be considered only after the observation
of gray hair and giant intracellular granules on a peripheral
blood smear, and light microscopy of a hair shaft can facilitate
a quick diagnosis [2]. We thought that the diagnosis could be
CHS because of the bone marrow aspiration and peripheral
blood smears findings (Figure 1b). Light microscopic images
of the patient’s hair showed abnormal clumping of melanin.
Pigment clumps were small and uniformly and regularly
distributed along the hair shaft (Figure 1c). Our patient was
therefore diagnosed by hair analysis although she does not
have the CHS phenotype (Figure 1d).
Patients with CHS may have a variable clinical presentation
due to different mutations in the LYST gene. Nonsense and
frameshift mutations of the LYST gene are associated with
severe early-onset childhood CHS and characterized by fatal
infections and HLH. Meanwhile, missense mutations of the
same gene are associated with milder, late-onset CHS with
slowly progressive neurological impairment or an adolescent
form with infections but no HLH [2,6,7]. In our case there is
probably a mutation of the LYST gene that is associated with
the normal phenotype and the specific findings of CHS on
peripheral blood smear, bone marrow aspiration smear, and
light microscopic image of the hair shaft but causes earlyonset
HLH. Genetic analysis is needed to explain this exactly.
In our case there was no specific treatment for CHS.
Intravenous antibiotherapy, erythrocyte suspension,
thrombocyte suspension, and, in accordance with the HLH
2004 protocol, dexamethasone and etoposide were used. The
patient has been positively responsive to chemotherapy and,
as the main treatment of CHS, SCT is planned, but a donor has
not yet been found [8].
In conclusion, we think that it is not necessary to find
oculocutaneous albinism and silvery hair in all patients to
diagnose CHS. Bone marrow aspiration and peripheral blood
smears and light microscopic images of the hair shaft may be
sufficient for diagnosis in some cases without genetic analysis.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
Key Words: Chediak-Higashi syndrome, Hemophagocytic
lymphohistiocytosis, Oculocutaneous albinism, Lyst gene,
Immune deficiency
Anahtar Sözcükler: Chediak-Higashi sendromu,
Hemofagositik lenfohistiositoz, Okülokütanöz albinizm, Lyst
geni, İmmün yetmezlik
References
1. Akbayram S, Akgun C, Basaranoglu M, Kaya A, Balta G,
Ustyol L, Yesilmen O, Deger I, Oner AF. A case of Chediak-
Higashi syndrome presented with hemophagocytic
lymphohistiocytosis. International Journal of Hematology
and Oncology 2011;21:196-199.
2. Spritz RA. Genetic defects in Chediak-Higashi syndrome
and the beige mouse. J Clin Immunol 1998;18:97-105.
3. Janka GE. Familial and acquired hemophagocytic
lymphohistiocytosis. Eur J Pediatr 2007;166:95-109.
4. Pujani M, Agarwal K, Bansal S, Ahmad I, Puri V, Verma D,
Pujani M. Chediak-Higashi syndrome - a report of two cases
with unusual hyperpigmentation of the face. Turk Patoloji
Derg 2011;27:246-248.
5. Karalı Z, Kılıç SŞ. Chediak-Higashi sendromu. Güncel
Pediatri Dergisi 2007;5:99-104 (article in Turkish).
6. Kaya Z, Ehl S, Albayrak M, Maul-Pavicic A, Schwarz K,
Kocak U, Ergun MA, Gursel T. A novel single point mutation
of the LYST gene in two siblings with different phenotypic
features of Chediak-Higashi syndrome. Pediatr Blood
Cancer 2011;56:1136-1139.
7. Westbroek W, Adams D, Huizing M, Koshoffer A, Dorward
H, Tinloy B, Parkes J, Helip-Wooley A, Kleta R, Tsilou E,
Duvernay P, Digre KB, Creel DJ, White JG, Boissy RE, Gahl
WA. Cellular defects in Chediak-Higashi syndrome correlate
with the molecular genotype and clinical phenotype. J Invest
Dermatol 2007;127:2674-2677.
8. Haddad E, Deist FL, Blanche S, Benkerrou M, Rohrlich P,
Vilmer E, Griscelli C, Fischer A. Treatment of Chediak-Higashi
syndrome by allogeneic bone marrow transplantation: report
of 10 cases. Blood 1995;85:3328-3333.
427

Letter to the Editor
DOI: 10.4274/tjh.2014.0019
Gaucher Cells or Pseudo-Gaucher Cells:
That’s the Question
Gaucher Hücreleri ya da Pseudo-Gaucher Hücreleri:
İşte Soru Bu
Deniz Gören Şahin 1 , Hava Üsküdar Teke 1 , Mustafa Karagülle 1 , Neslihan Andıç 1 , Eren Gündüz 1 , Serap Işıksoy 2 ,
Olga Meltem Akay 1
1 Eskişehir Osmangazi University Faculty of Medicine, Department of Hematology, Eskişehir, Turkey
2 Eskişehir Osmangazi University Faculty of Medicine, Department of Pathology, Eskişehir, Turkey
To the Editor,
Bone marrow cells with morphological characteristics
similar to Gaucher cells and without cytoplasmic crystalline
inclusions are rare. These Gaucher-like or pseudo-Gaucher
cells can be seen in a variety of conditions such as acute
lymphoblastic leukemia, multiple myeloma, myelodysplasia,
Hodgkin’s disease, thalassemia, and disseminated
mycobacterial infection [1,2,3,4,5,6,7,8]. Since the presence of
these cells may obscure neoplastic cells in multiple myeloma
and may lead to misdiagnosis, it is important for hematologists
and hematopathologists to be aware of such a condition in
order to make a prompt and accurate diagnosis. Herein we
report a case of multiple myeloma in which the presence of
plasma cells was missed on initial histological diagnosis.
A 44-year-old female without history of any previous
systemic disease presented with oliguria, easy fatigability, and
breathlessness for 7 days. On examination she had crepitating
rales, jugular venous congestion, abdominal distension, and
pretibial edema. The complete blood count showed Hb of 67
g/L, WBC count of 3.4x109/L, and platelet count of 69x10 9 /L.
Erythrocyte sedimentation rate was 112 mm/h. Bone marrow
aspirate and biopsy were performed. The bone marrow aspirate
revealed numerous large cells with plentiful cytoplasm and a
small eccentric nucleus. Scattered among these were plasma
cells, which were obscured by sheets of Gaucher-like cells
(Figure 1A). Immunohistochemical staining of bone marrow
biopsy showed that plasma cells were positive for CD38 and
kappa light chain (Figures 1B and 1C), and the large cells
were positive for CD68 (Figure 1D). There were crystalline
Figure 1. (A) Bone marrow aspirate smear (Giemsa 400x)
showing pseudo-Gaucher cells with abundant cytoplasm,
dense round deposits, and an eccentric pyknotic nucleus;
immunohistochemical staining of bone marrow biopsy
showed that plasma cells were positive for (B) CD38 and (C)
kappa light chain; (D) the large cells were positive for CD68.
inclusion bodies within these cells, which were negative for
smooth muscle actin, HHF-35, and keratin. The erythroid and
myeloid series were normal. Serum electrophoresis revealed
an M band. Skull X-ray showed lytic bone lesions. Taken
together, a diagnosis of multiple myeloma associated with a
prominent pseudo-Gaucher histiocytic response was made.
Gaucher-like cells have been described in various
hematological disorders [1,2,3,4,5,6,7,8]. These cells are
considered to be marrow macrophages seen in circumstances
Address for Correspondence: Olga Meltem AKAY, M.D.,
Eskişehir Osmangazi University Faculty of Medicine, Department of Hematology, Eskişehir, Turkey
Phone: +90 222 239297 E-mail: olga.akay@hotmail.com
Received/Geliş tarihi : January 13, 2014
Accepted/Kabul tarihi : May 13, 2014
428

Gören Şahin D, et al: Pseudo-Gaucher Cells
Turk J Hematol 2014;31:428-429
related to high cell turnover [9]. One striking feature is that
pseudo-Gaucher cells cannot be distinguished from true
Gaucher cells by routine hematoxylin-eosin staining. In order
to differentiate them, iron staining should be performed.
Gaucher cells show diffuse iron staining whereas pseudo-
Gaucher cells do not. Electron microscopical features may also
help distinguish pseudo-Gaucher cells from true Gaucher cells.
On electron microscopy, pseudo-Gaucher cells do not contain
typical tubular cytoplasmic inclusions, which are present in
Gaucher cells. In addition, crystal-storing histiocytosis and
sea blue histiocytosis should be considered in differential
diagnosis. Macrophages with cytoplasmic crystalline
inclusions are better regarded as crystal-storing histiocytes and
this rare entity could be confused with Gaucher or pseudo-
Gaucher cells [10]. Moreover, sea blue histiocytes should be
kept in mind. However, these cells are heavily granulated with
prominent vacuolation. We are reporting this case to increase
the awareness among hematologists and hematopathologists of
this rare association to avoid misdiagnosis. We also would like
to highlight that the presence of pseudo-Gaucher cells in bone
marrow should not be overlooked as they might be obscuring
an underlying pathology. Awareness of possible associations,
appropriate immunohistochemistry, and relevant additional
investigations based on clinical findings are necessary for final
diagnosis.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
Key Words: Crystalline inclusion bodies, Gaucher cells,
Multiple myeloma
Anahtar Sözcükler: Kristal inklüzyon cisimcikler, Gaucher
hücreleri, Multiple miyeloma
References
1. Busarla SV, Sadruddin FA, Sohani AR. Pseudo-Gaucher cells
in disseminated mycobacterial infection. Am J Hematol
2013;88:155.
2. Bain BJ, Lee L. Pseudo-Gaucher cells in sickle cell anemia.
Am J Hematol 2010;85:435.
3. Ash Image Bank. Waldenström macroglobulinemia with
pseudo-Gaucher cells. Blood 2010;116:3388.
4. Saroha V, Gupta P, Singh M, Singh T. Pseudogaucher
cells obscuring multiple myeloma: a case report. Cases J
2009;2:9147.
5. Sharma P, Khurana N, Singh T. Pseudo-Gaucher cells in
Hb E disease and thalassemia intermedia. Hematology
2007;12:457-459.
6. Saito T, Usui N, Asai O, Dobashi N, Ida H, Kawakami M, Yano
S, Osawa H, Takei Y, Takahara S, Ogasawara Y, Yamaguchi
Y, Minami J, Aiba K. Pseudo-Gaucher cell proliferation
associated with myelodysplastic syndrome. Int J Hematol
2007;85:350-353.
7. Zidar BL, Hartsock RJ, Lee RE, Glew RH, LaMarco KL, Pugh
RP, Raju RN, Shackney SE. Pseudo-Gaucher cells in the
bone marrow of a patient with Hodgkin’s disease. Am J Clin
Pathol 1987;87:533-536.
8. Scullin DC Jr, Shelburne JD, Cohen HJ. Pseudo-Gaucher
cells in multiple myeloma. Am J Med 1979;67:347-352.
9. Carrington PA, Stevens RF, Lendon M. Pseudo-Gaucher
cells. J Clin Pathol 1992;45:360.
10. Schaefer HE. Gammopathy-related crystal-storing
histiocytosis, pseudo- and pseudo-pseudo-Gaucher cells.
Critical commentary and mini-review. Pathol Res Pract
1996;11:1152-1162.
429

Letter to the Editor
DOI: 10.4274/tjh.2014.0052
Quilty Effect after Extracorporeal Photopheresis in a
Patient with Severe Refractory Cardiac Allograft Rejection
Şiddetli Kardiyak Allogreft Rejeksiyonu Olan Bir Hastada
Ekstrakorporeal Fotoferez Sonrası Quilty Etkisi
Özgür Ulaş Özcan 1 , Tamer Sayın 1 , Gürbey Soğut 1 , Aylin Heper 2 , Hüseyin Göksülük 1 , Veysel Kutay Vurgun 1 ,
Cansın Tulunay Kaya 1 , Elif Ezgi Üstün 1 , Osman İlhan 3 , Çetin Erol 1
1 Ankara University Faculty of Medicine, Department of Cardiology, Ankara, Turkey
2 Ankara University Faculty of Medicine, Department of Pathology, Ankara, Turkey
3 Ankara University Faculty of Medicine, Department of Hematology, Ankara, Turkey
To the Editor,
Solid organ transplant rejection is still a problem despite
the use of immunosuppressive therapy. The currently available
regimens for transplant rejection may predispose patients
to malignancies such as nonmelanoma skin cancers and
opportunistic infections [1]. Extracorporeal photopheresis
(ECP) is a leukapheresis-based immunomodulatory therapy
in which lymphocytes collected from the patient are incubated
with 8-methoxypsoralen, a photosensitizing agent, in the
presence of UV-A radiation and then reinfused into the patient
[2]. Here we report a case of severe refractory cardiac allograft
rejection that was successfully treated by ECP.
A 47-year-old man presented with severe decompensated
heart failure and hemodynamic compromise 13 months
after heart transplantation. Ejection fraction was 25% with
transthoracic echocardiography. After immediate therapy
with positive inotropes and diuretics, diagnostic coronary
angiography, right heart catheterization, and endomyocardial
biopsy were performed. Coronary angiography revealed no
obstructive coronary artery disease. The endomyocardial
biopsy showed perivascular and interstitial lymphocytic
inflammatory infiltrate with sparse eosinophils in 2 separate
locations that were identified as moderate acute cellular
rejection (ISHLT 2R). Cyclosporin A level was 150 ng/
mL. Methylprednisolone pulses (1 g/day) for 3 days and
equine anti-thymocyte globulin (Atgam) at 15 mg/kg/
day were administered for induction therapy. Due to the
deterioration of clinical status and intervening pneumonia,
immunosuppressive therapy was ceased and ECP was planned.
Figure 1. Endomyocardial biopsy specimen demonstrated
endocardial lymphocytic aggregate.
ECP sessions were performed twice a week for 2 months.
After therapy the patient became minimally symptomatic
with an ejection fraction of 50%. Repeated endomyocardial
biopsy demonstrated lymphocytic aggregation confined to
the endocardium, which was interpreted as Quilty effect, and
remission of acute cellular rejection (Figure 1). The patient
was discharged asymptomatically. Informed consent was
obtained.
Transplant rejection of solid organs remains an issue despite
modern immunosuppressive regimens. The rate of rejection
is 25% during the first year after heart transplantation [1].
Address for Correspondence: Özgür Ulaş ÖZCAN, M.D.,
Ankara University Faculty of Medicine, Department of Cardiology, Ankara, Turkey
Phone: +90 312 508 24 10 E-mail: ozgurulasozcan@yahoo.com.tr
Received/Geliş tarihi : February 3, 2014
Accepted/Kabul tarihi : June 9, 2014
430

Özcan UÖ, et al: Extracorporeal Photopheresis in Acute Setting
Turk J Hematol 2014;31:430-431
Acute cell-mediated rejection is characterized by infiltration
of T cells directed against the allograft [3]. Biopsy grades of
>2 R warrant accentuation of immunosuppression [4]. ‘Quilty
effect’ refers to lymphocytic infiltration in the endocardium
of cardiac allografts. Although the clinical significance of
the Quilty effect is not fully known, it is understood that the
Quilty effect does not reflect transplant rejection.
Hemodynamic compromise, persistence or recurrence
of rejection, and side effects or complications associated
with intensive immunosuppressive therapy necessitate
alternative approaches for handling rejection. ECP is indicated
for prevention of acute and chronic rejection of cardiac
transplants [5,6,7]. Favorable effects were also demonstrated
for secondary prevention among patients with a history of
acute rejection [8]. ECP is a relatively safe procedure. Serious
side effects are rarely reported, most of which are related
to hypotension and anemia secondary to volume changes
and blood loss during the procedure. Risks of opportunistic
infections or secondary malignancies have not been increased
because of ECP [9]. Small studies demonstrated the benefits of
ECP for primary and secondary prevention of cardiac allograft
rejection, but treatment for acute refractory cardiac allograft
rejection is questionable because of the scarcity of data. We
suggest the use of ECP for this compelling condition.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
Key Words: Allograft, Extracorporeal photopheresis,
Heart transplantation, Quilty effect, Rejection
Anahtar Sözcükler: Allogreft, Ekstrakorporeal fotoferez,
Kalp transplantasyonu, Quilty etkisi, Rejeksiyon
References
1. Taylor DO, Stehlik J, Edwards LB, Aurora P, Christie
JD, Dobbels F, Kirk R, Kucheryavaya AY, Rahmel AO,
Hertz MI. Registry of the International Society for Heart
and Lung Transplantation: Twenty-sixth Official Adult
Heart Transplant Report-2009. J Heart Lung Transplant
2009;28:1007-1022.
2. Marques MB, Schwartz J. Update on extracorporeal
photopheresis in heart and lung transplantation. J Clin
Apher 2011;26:146-151.
3. Stewart S, Winters GL, Fishbein MC, Tazelaar HD,
Kobashigawa J, Abrams J, Andersen CB, Angelini A, Berry
GJ, Burke MM, Demetris AJ, Hammond E, Itescu S, Marboe
CC, McManus B, Reed EF, Reinsmoen NL, Rodriguez ER,
Rose AG, Rose M, Suciu-Focia N, Zeevi A, Billingham
ME. Revision of the 1990 working formulation for the
standardization of nomenclature in the diagnosis of heart
rejection. J Heart Lung Transplant 2005;24:1710-1720.
4. Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M,
Desai S, Fedson S, Fisher P, Gonzales-Stawinski G, Martinelli
L, McGiffin D, Smith J, Taylor D, Meiser B, Webber S, Baran
D, Carboni M, Dengler T, Feldman D, Frigerio M, Kfoury
A, Kim D, Kobashigawa J, Shullo M, Stehlik J, Teuteberg J,
Uber P, Zuckermann A, Hunt S, Burch M, Bhat G, Canter
C, Chinnock R, Crespo-Leiro M, Delgado R, Dobbels F,
Grady K, Kao W, Lamour J, Parry G, Patel J, Pini D, Towbin
J, Wolfel G, Delgado D, Eisen H, Goldberg L, Hosenpud J,
Johnson M, Keogh A, Lewis C, O’Connell J, Rogers J, Ross
H, Russell S, Vanhaecke J. International Society of Heart and
Lung Transplantation Guidelines. The International Society
of Heart and Lung Transplantation Guidelines for the care
of heart transplant recipients. J Heart Lung Transplant
2010;29:914-956.
5. Szczepiorkowski ZM, Winters JL, Bandarenko N, Kim
HC, Linenberger ML, Marques MB, Sarode R, Schwartz J,
Weinstein R, Shaz BH. Apheresis Applications Committee
of the American Society for Apheresis. Guidelines on the use
of therapeutic apheresis in clinical practice--evidence-based
approach from the Apheresis Applications Committee of the
American Society for Apheresis. J Clin Apher 2010;25:83-
177.
6. Barr ML, Meiser BM, Eisen HJ, Roberts RF, Livi U,
Dall’Amico R, Dorent R, Rogers JG, Radovancevic B,
Taylor DO, Jeevanandam V, Marboe CC. Photopheresis
for the prevention of rejection in cardiac transplantation.
Photopheresis Transplantation Study Group. N Engl J Med
1998;339:1744-1751.
7. Barr ML, Baker CJ, Schenkel FA, McLaughlin SN, Stouch
BC, Starnes VA, Rose EA. Prophylactic photopheresis and
chronic rejection: effects on graft intimal hyperplasia in
cardiac transplantation. Clin Transplant 2000;14:162-166.
8. Kirklin JK, Brown RN, Huang ST, Naftel DC, Hubbard SM,
Rayburn BK, McGiffin DC, Bourge RB, Benza RL, Tallaj
JA, Pinderski LJ, Pamboukian SV, George JF, Marques
M. Rejection with hemodynamic compromise: objective
evidence for efficacy of photopheresis. J Heart Lung
Transplant 2006;25:283-288.
9. Hart JW, Shiue LH, Shpall EJ, Alousi AM. Extracorporeal
photopheresis in the treatment of graft-versus-host disease:
evidence and opinion. Ther Adv Hematol 2013;4:320-334.
431

Letter to the Editor
DOI: 10.4274/tjh.2014.0206
A Pediatric Patient with Intravenous Cyclosporine
Anaphylaxis Who Tolerated the Oral Form
İntravenöz Siklosporin ile Anafilaksiye Giren ve Oral Formu
Tolere Eden Bir Pediatrik Olgu
Pamir Işık 1 , Namik Özbek 1 , Emine Dibek Mısırlıoğlu 2 , Turan Bayhan 3 , Suna Emir 1 , Fatih Mehmet Azık 1 ,
Bahattin Tunç 1
1 Ankara Children’s Hematology and Oncology Education and Research Hospital, Clinic of Pediatric Hematology, Ankara, Turkey
2 Ankara Children’s Hematology and Oncology Education and Research Hospital, Clinic of Pediatric Allergy, Ankara, Turkey
3 Hacettepe University Faculty of Medicine, Division of Pediatric Hematology, Ankara, Turkey
To the Editor,
Cyclosporine is a potent immune suppressant and prevents
T-cell activation and graft-versus-host disease by inhibiting
calcineurin phosphatase [1,2]. Anaphylactic reaction due to
intravenous infusion is a rare side effect, reported in 0.1% of
patients [3,4]. Cremophor EL (polyoxyethylated castor oil),
a solubilizing agent of the parenteral cyclosporine, has been
blamed for hypersensitivity reactions [5]. Here we report
a patient who developed anaphylaxis due to an intravenous
form of cyclosporine.
A 17-year-old boy, diagnosed with relapsed T-cell
lymphoblastic lymphoma after achieving complete remission,
underwent bone marrow transplantation from his fully
matched brother. Intravenous cyclosporine (3 mg/kg/day) was
started at day -1. At day +10, he developed a maculopapular rash
on his trunk, fever, and weight gain, diagnosed as engraftment
syndrome. His symptoms improved with intravenous
methylprednisolone treatment (2 mg/kg/day). At day +14, at
10 min after the start of cyclosporine infusion, he developed
disseminated erythematous rash, respiratory distress, severe
chest pain, and facial edema. His systolic blood pressure was
within the normal range, but his pulse rate decreased to 50/
min. Cyclosporine infusion was stopped and adrenaline,
methylprednisolone, and pheniramine were intravenously
administered. His complaints resolved within 30 min. We
concluded that this reaction had occurred against the castor
oil that exists in the intravenous form. Since cyclosporine
treatment was crucial, we decided to give a capsule formulation
that did not contain castor oil (Panosporin®). The capsule
was given in a 3-dose graded challenge (25 mg, 25 mg, and
50 mg with 30-min intervals) without significant reaction. In
the following period he received scheduled doses without any
problem. Skin tests performed with intravenous cyclosporine
5 months after anaphylaxis revealed positive results in our
patient, but the test was negative for the donor. Informed
consent was obtained.
Polyoxyethylated castor oil has been associated with severe
anaphylaxis [6]. A recent report concerning cyclosporineinduced
anaphylaxis revealed that 11 patients had a reaction
with the intravenous form. Seven of these patients tolerated
an oral formulation of cyclosporine. It was claimed that
hypersensitivity reaction to one formulation of cyclosporine
does not preclude the use of a different formulation [5].
Some patients in the literature were reported to have allergic
reactions to a parenteral form of both cyclosporine and
tacrolimus attributed to castor oil, which is present in the
formulation of both drugs [7,8]. Those patients had tolerated
the oral formulation of cyclosporine without castor oil, as
did our patient. Since the oral form of Panosporin® does not
contain castor oil, we chose this drug for treatment for our
patient without further reactions.
Proposed mechanisms related to allergic reactions
due to polyoxyethylated castor oil include IgE-mediated
hypersensitivity, complement activation, and mast cell
degranulation [5]. Our patient had a positive intradermal
test for intravenous cyclosporine including polyoxyethylated
castor oil. The positivity of the intradermal test suggested
an IgE-mediated reaction. Interestingly, intensive immune
Address for Correspondence: Pamir IŞIK, M.D.,
Ankara Children’s Hematology and Oncology Education and Research Hospital, Clinic of Pediatric Hematology, Ankara, Turkey
Phone: +90 312 596 98 74 E-mail: pamir1968@yahoo.com
Received/Geliş tarihi : May 26, 2014
Accepted/Kabul tarihi : July 1, 2014
432

Işık P, et al: Intravenous Cyclosporine Anaphylaxis
Turk J Hematol 2014;31:432-433
suppression in bone marrow recipients may facilitate the
rare reaction to castor oil [7]. In conclusion, in the case
of anaphylaxis with the parenteral form, oral products of
cyclosporine that do not contain castor oil can be tried in
patients who underwent bone marrow transplantation.
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
Key Words: Cyclosporine, Toxicity, Stem cell
transplantation
Anahtar Sözcükler: Siklosporin, Yan etki, Kök hücre nakli
References
1. Bickel M, Tsuda H, Amstad P, Evequoz V, Mergenhagen
SE, Wahl SM, Pluznik DH. Differential regulation of
colony-stimulating factors and interleukin 2 production
by cyclosporin A. Proc Natl Acad Sci U S A 1987;84:3274-
3277.
2. Ringden O. Cyclosporine in allogeneic bone marrow
transplantation. Transplantation 1986;42:445-452.
3. Beauchesne PR, Chung NS, Wasan KM. Cyclosporine A:
a review of current oral and intravenous delivery systems.
Drug Dev Ind Pharm 2007;33:211-220.
4. Kuiper RA, Malingré MM, Beijnen JH, Schellens JH.
Cyclosporine-induced anaphylaxis. Ann Pharmacother
2000;34:858-861.
5. Volcheck GW, Van Dellen RG. Anaphylaxis to intravenous
cyclosporine and tolerance to oral cyclosporine: case report
and review. Ann Allergy Asthma Immunol 1998;80:159-
163.
6. Gelderblom H, Verweij J, Nooter K, Sparreboom A.
Cremophor EL: the drawbacks and advantages of vehicle
selection for drug formulation. Eur J Cancer 2001;37:1590-
1598.
7. Takamatsu Y, Ishizu M, Ichinose I, Ogata K, Onoue
M, Kumagawa M, Suzumiya J, Tamura K. Intravenous
cyclosporine and tacrolimus caused anaphylaxis but oral
cyclosporine capsules were tolerated in an allogeneic bone
marrow transplant recipient. Bone Marrow Transplant
2001;28:421-423.
8. Nicolai S, Bunyavanich S. Hypersensitivity reaction to
intravenous but not oral tacrolimus. Transplantation
2012;94:61-63.
433

Letter to the Editor
DOI: 10.4274/tjh.2014.0252
Acquired Hemophilia
Kazanılmış Hemofili
Şinasi Özsoylu
Retired Professor of Pediatrics, Hematology and Hepatology, Honorary Fellow of American Academy of Pediatrics, Honorary Member of American
Pediatric Society
To the Editor,
I would like to highlight 3 of our patients, a 14-year-old
boy and females of 4 and 41 years old [1,2] with acquired
hemophilia B seen at İhsan Doğramacı Children’s Hospital
(previously Hacettepe) between 1963 and 1973 among
343 patients with hemophilia [3] on account of the case
of acquired hemophilia A in a 78-year-old man who was
successfully treated with a combined immunosuppressive and
immunoadsorption approach by Bilgin et al. as reported in a
recent issue of this journal [4].
Two of our 3 patients with acquired hemophilia B, which is
rarer than acquired hemophilia A, improved most likely due to
corticosteroid administration in at least one case and without
any intervention in the others. We have shown antibodies
against factor VIII in more than 20% of patients with X-linked
hemophilia A and extremely rarely in normal people in low
titers [3]; however, very severe bleeding due to the presence of
AHG antibodies was not frequent.
On this occasion I would rather use the term ‘hereditary’
instead of ‘congenital’ hemophilia, which was used by Bilgin
et al., since inheritance is not involved in most congenital
disorders, such as congenital tuberculosis, syphilis, CMV,
rubella infection, etc. May I also indicate that methyl
prednisolone at 1 mg/kg/day may not be effective as an
immunosuppressive, but 30 mg/kg/day seems to be more
effective?
Conflict of Interest Statement
The authors of this paper have no conflicts of interest,
including specific financial interests, relationships, and/or
affiliations relevant to the subject matter or materials included.
Key Words: Acquired hemophilia
Anahtar Sözcükler: Kazanılmış hemofili
References
1. Özsoylu S. Bir kız çocuğunda geçici hemofili B. Çocuk Sag
ve Hast Dergisi 1964;7:101-107.
2. Özsoylu S, Özer F. Acquired factor IX deficiency: a report of
two cases. Acta Haemat 1973;50:305-314.
3. Özsoylu S, Yamak B, Hiçsönmez G, Yetgin S, Pirnar A.
Evaluation of 343 cases of hemophilia. Excerpta Med Int
Congr Ser 1974;356:158-161.
4. Bilgin AU, Özcan M, Ayyıldız E, İlhan O. The treatment
of acquired hemophilia with combination therapy of
immunosuppressives and immunoadsorption. Turk J
Hematol 2014;31:194-197.
Reply
I would like to thank you for your comment and interest in my article. Firstly you are right about this subject; hemophilia is
a genetic disorder. However, congenital hemophilia is a term that can be used in literature. Secondly high dose of steroid was not
preferred for this patient because of his age and comorbid disease.
Aynur UĞUR BİLGİN
Address for Correspondence: Şinasi ÖZSOYLU, M.D.,
Retired Professor of Pediatrics, Hematology and Hepatology, Honorary Fellow of American Academy of Pediatrics, Honorary Member of American Pediatric Society
E-mail: sinasiozsoylu@hotmail.com
Received/Geliş tarihi : June 21, 2014
Accepted/Kabul tarihi : June 23, 2014
434

Images in Hematology
DOI: 10.4274/tjh.2013.0364
Clinical Image in Hematology
Generalized Necrobiotic Xanthogranuloma in a Patient with Multiple Myeloma
Multipl Myeloma Tanılı Bir Hastada Yaygın Nekrobiyotik Ksantogranüloma
Figure 1. Dermatological lesions.
435

Turk J Hematol 2014;31:435-436
Clinical Image in Hematology
Figure 2. Morphological analysis of the bone marrow aspirate
demonstrated abnormal plasma cells.
Figure 3. Skin biopsy studies revealed 2 granulomas containing
Touton giant cells and foamy histiocytes.
Analysis of a skin biopsy obtained from a 42-year-old female presenting with multiple yellowish to reddish-brown nodules
and plaques on the arm, chest (Figure 1), and abdomen showed that she had generalized necrobiotic xanthogranuloma (Figure
3). Informed consent was obtained.
A week later, she was diagnosed with IgG-kappa multiple myeloma (Figure 2).
The laboratory workup showed the following: Hb: 109 g/L, Hct: 0.34 L/L, WBC: 9.5x10 9 /L, Plt: 194x10 9 /L, with normal
differential white cell count. Other studied parameters included immunoglobulin IgG:1790 mg/dL (normal range: 750-1750),
IgA: 279 mg/dL (normal range: 90-450), IgM: 40 mg/dL (normal range: 70-280); and kappa light chains: 1830 mg/dL (normal
range: 629-1320 mg/dL).
The coexistence of paraproteinemias and necrobiotic xanthogranuloma is well described (above all, monoclonal gammopathy
of unknown significance), and it would seem reasonable to recommend performing at least serum electrophoresis for patients
affected by these rare conditions [1].
Conflict of Interest Statement
The authors of this paper have no conflicts of interest, including specific financial interests, relationships, and/or affiliations
relevant to the subject matter or materials included.
Key Words: Multiple, Myeloma, Skin, Necrobiotic, Xanthogranuloma
Anahtar Sözcükler: Multipl, Myeloma, Deri, Nekrobiyotik, Ksantogranüloma
Maria Jimenez Esteso, Jose Verdu, Francisco de Paz, Fabian Tarin
University General Hospital of Alicante, Clinic of Hematology and Hemotherapy, Alicante, Spain
Phone: +0096 591 38 71 E-mail: pepeverd@hotmail.com
Received/Geliş tarihi : October 30, 2013
Accepted/Kabul tarihi : November 11, 2013
Reference
1. Rose A, Robinson M, Kamino H, Latkowski JA. Necrobiotic xanthogranuloma. Dermatol Online J 2012;18:30.
436

DOI: 10.4274/tjh.2013.0104
Aggressive Multiple Myeloma with Unusual Morphology
Olağan Dışı Morfoloji ile Multipl Miyelom
Morphology in Hematology
Figure 1. Atypical and multinucleated plasma cell infiltration in the bone marrow aspirate (Wright’s stain, 100x).
A 66-year-old male patient was admitted to the hospital with backache, fatigue, and paraesthesia and spasm in both legs. He
had lower extremity numbness and bladder and bowel incontinence. Physical examination revealed the absence of bilateral lower
extremity reflexes and lower extremity weakness. Magnetic resonance imaging showed a large mass extending from T8 to T9,
fracture of T9, and compression of the spinal cord. Informed consent was obtained.
Laboratory results at initial evaluation revealed the following: haemoglobin: 118 g/L, haematocrit: 33.5%, white blood cell
count: 6.7x109/L, platelets: 192x10 9 /L, blood urea nitrogen: 7.5 mmol/L, creatinine: 113.1 µmol/L, calcium: 1.9 mmol/L, total
protein: 63 g/L; albumin: 31 g/L; and erythrocyte sedimentation rate: 59 mm/h. Protein studies by nephelometry revealed IgA of
4.25 g/L (reference range: 0.7-4 g/L) and lambda light chain of 3.98 g/L (reference range: 0.9-2.1 g/L). A small monoclonal spike
was present upon protein electrophoresis. Urine immunoelectrophoresis documented no monoclonal light chain. Bone marrow
aspirate and biopsy were performed and the patient underwent surgical decompression and stabilisation of the thoracic spine. The
bone marrow aspirate and biopsy morphology showed infiltration with atypical, multilobated, cleaved, and monocytoid nuclei
plasma cells (Figures 1 and 2). The biopsy material stained positive with lambda light chain and CD138.
437

Turk J Hematol 2014;31:437-438
Morphology in Hematology
Figure 2. Atypical and multinucleated plasma cell infiltration in the bone marrow biopsy (H&E, 20x).
The neoplastic plasma cells exhibit a variety of morphologies. Poorly differentiated plasma cells may show atypical
morphology, making it difficult to recognise their plasma cell nature. Plasma cell morphology correlates with disease course,
prognosis, and resistance to conventional treatment [1,2,3].
Conflict of Interest Statement
The authors of this paper have no conflicts of interest, including specific financial interests, relationships, and/or affiliations
relevant to the subject matter or materials included.
Key Words: Multiple myeloma, Unusual morphology
Anahtar Sözcükler: Multipl miyelom, Olağan dışı morfoloji
Mehmet Sönmez 1 , Hasan Mücahit Özbaş 1 , Nilay Ermantaş 1 , Ümit Çobanoğlu 2
1Karadeniz Technical University Faculty of Medicine, Department of Hematology, Trabzon, Turkey
2Karadeniz Technical University Faculty of Medicine, Department of Pathology, Trabzon, Turkey
Phone: +90 462 377 58 48 E-mail: mesonmez@yahoo.com
Received/Geliş tarihi : March 20, 2013
Accepted/Kabul tarihi : April 25, 2013
References
1. Stifter S, Babarovic E, Valkovic T, Seili-Bekafigo I, Stemberger C, Nacinovic A, Lucin K, Jonjic N. Combined evaluation of
bone marrow aspirate and biopsy is superior in the prognosis of multiple myeloma. Diagn Pathol 2010;5:30.
2. Kyle RA, Rajkumar SV. Criteria for diagnosis, staging, risk stratification and response assessment of multiple myeloma.
Leukemia 2009;23:3-9.
3. Erkut N, Çobanoğlu Ü, Sönmez M. Multiple myeloma with multilobated plasma cell nuclei. Turk J Hematol 2011;28:158-
159.
438

31 st Volume Index / 31. Cilt Dizini
SUBJECT INDEX - KONU DİZİNİ
2014
Abnormal Hemoglobins
Hemoglobin / Hemoglobin, 97
Variant / Varyant, 97
Hemoglobinopathy / Hemoglobinopati, 97
Hb Lansing / Hb Lansing, 317
Abnormal hemoglobin / Anormal hemoglobin, 317
Alpha-globin / Alfa globin, 317
Hemoglobinopathy / Hemoglobinopati, 319
Hb Jabalpur / Hb Jabalpur, 319
High performance liquid chromatography /
Yüksek performanslı sıvı kromatografisi, 319
Acute Leukemia
Acute myeloid leukemia / Akut miyeloid lösemi, 40,128,143,149
NPM1 gene type A mutation / NPM1 geni tip A mutasyonu, 40
FLT3-ITD / FLT3-ITD, 40
Allele-specific polymerase chain reaction/ Allel-özgül polimeraz
zincir reaksiyonu, 40
T-cell prolymphocytic leukemia / T-hücreli prolenfositik lösemi, 75
Cerebral involvement / Serebral tutulum, 75
Central nervous system / Santral sinir sistemi, 75
Stereotactic biopsy / Stereotaktik biyopsi, 75
LYL1 gene / LYL1 geni, 128
Myelodysplastic syndrome / Miyelodisplastik sendrom, 128
Chronic myelogenous leukemia in blast and accelerated phases /
Akselere ve blastik evre kronik miyeloid lösemi, 128
Real-time polymerase chain reaction / Gerçek-zamanlı polimeraz
zincir reaksiyonu, 128
Cytogenetically normal / Sitogenetiği normal, 143
Mutations / Mutasyonlar, 143
Prognosis / Prognoz, 143
Wilms tumor 1 gene / Wilms tümör 1 geni, 143
Cytokines / Sitokinler, 149
Granulocyte colony-stimulating factor / Granülosit koloni
büyüme etkeni, 149
RT-PCR / RT-PCR, 149
Acute lymphoblastic leukemia / Akut lenfoblastik lösemi, 203
Isolated breast relapse / İzole meme nüksü, 203
Leukemia cutis / Lösemi kutis, 213
Aleukemic leukemia / Aleukemic lösemi, 213
Persistent / Persistan, 213
Thalassemia intermedia / Talasemi intermedia, 311
Leukemia / Lösemi, 311,321
Cancer / Kanser, 311
Infection / İnfeksiyon, 321
Liver abscess / Karaciğer absesi, 321
Clofarabine / Clofarabine, 325
Multi-relapsed Leukemia / Çoklu relaps lösemi, 325
Children / Çocuk, 325
Relaps / Relaps 325
Myelosuppression / Miyelosupresyon, 399
Thiopurine S-methyl transferase / Thiopurin S-metil transferaz, 399
Acute leukemia / Akut lösemi, 399
Anemia
Microcytosis / Mikrositoz, 339
Sideroblastic anemia / Sideroblastik anemi, 339
Zinc deficiency / Çinko eksikliği, 339
Aplastic Anemia
Mesenchymal stem cell / Mezenkimal kök hücreler, 180
Immune recovery / İmmün yeniden yapılanma, 180
Aplastic anemia / Aplastik anemi, 180,411
Allogeneic stem cell transplantation /
Allogenik kök hücre nakli, 180
Onychomycosis/ Onikomikoz, 411
Terbinafine / Terbinafin, 411
Hematological toxicity / Hematolojik toksisite, 411
Pancytopenia / Pansitopeni, 411
Adverse events / Yan etkiler, 411
Autoimmune Hemolytic Anemia
Autoimmune hemolytic anemia / Otoimmün hemolitik anemi, 328
Bone Marrow
Cystinosis / Sistinozis, 106
Bone marrow / Kemik iliği, 106
Examination / İnceleme, 106
Gelatinous transformation / Jelatinöz transformasyon, 175
Bone marrow / Kemik iliği, 175
Sarcoidosis / Sarkoidoz, 192
Bone / Kemik, 192

Bone marrow / Kemik iliği, 192
Hematologic manifestations of systemic diseases /
Sistemik hastalıkların hematolojik belirtileri, 211
Lymphoid cells neoplasms / Lenfoid hücreler tümörleri, 211
Bone marrow failure / Kemik iliği yetmezliği, 211
Sensitized serum / Sensitize serum, 266
Bone marrow cells / Kemik iliği hücreleri, 266
Rejection / Rejeksiyon, 266
Transplantation / Transplantasyon, 266
Angiosarcoma / Anjiosarkom, 408
Splenomegaly / Splenomegali, 408
Bone marrow infiltration / Kemik iliği tutulumu, 408
Chediak-Higashi Syndrome
Chediak-Higashi syndrome /
Chediak-Higashi sendromu, 210,313,426
Giant granules / Dev granüller, 210
Erytrophagocytosis / Eritrofagositoz, 210
Child / Çocuk, 313
Oral lesions / Oral lezyonlar, 313
Hemophagocytic lymphohistiocytosis /
Hemofagositik lenfohistiositoz, 426
Oculocutaneous albinism / Okülokütanöz albinizm, 426
Lyst gene / Lyst geni, 426
Immune deficiency / İmmün yetmezlik, 426
Chemotherapy
Doxorubicin / Doksorubisin, 68
Nitric oxide / Nitrik oksit, 68
Nitric oxide synthase inhibitors /
Nitrik oksit sentaz inhibitörleri, 68
Chronic Leukemia
PDGFRA / PDGFRA, 56
Chronic eosinophilic Leukemia / Kronik eozinofilik lösemi, 56
Imatinib / İmatinib, 56
India / Hindistan, 56
Lymphoma / Lenfoma, 92
Chronic myeloid leukemia / Kronik myeloid lösemi, 92
Secondary malignancy / Sekonder malignite, 92
Coagulation
Blood coagulation / Kan koagülasyonu, 261
Colloids/ Kolloidler, 261
Genital neoplasms / Genital neoplaziler, 261
Thromboelastography / Trombelastografi, 261
Granulocytic Sarcoma
Granulocytic sarcoma / Granülositik sarkom, 88
Breast / Meme, 88
Stem cell transplantation / Kök hücre nakli, 88
18FDG-PET/CT / 18FDG-PET/CT, 88
Hematological Malignancies
Invasive fungal infection / İnvazif fungal infeksiyonlar, 111, 342
Antifungal treatment / Antifungal tedavi, 111
Evidence / Kanıt, 111
Hematological malignancies / Hematolojik malignansi, 111
Acute myeloblastic leukemia / Akut miyeloblastik lösemi, 201
Granulocytes / Granülositler, 201
Acute leukemia / Akut lösemi, 201
Hemophagocytic lymphohistiocytosis /
Hemofagositik lenfohistiositoz, 201
Extramedullary myeloid tumor / Extramedüller miyeloid tümör, 295
Pancreas / Pankreas, 295
Allogeneic stem cell transplantation /
Allogeneik kök hücre nakli, 295
Diagnosis / Tanı, 342
Imaging / Görüntüleme, 342
Serology / Seroloji, 342
Plasmacytoid dendritic cell / Plazmasitoid Dendritik Hücre, 422
Leukemia / Lösemi, 422
Cutaneous lesion / Deri Lezyonu, 422
CD4 (+) / CD4 (+), 422
CD56 (+) / CD56 (+), 422
Hemophagocytic Lymphohistiocytosis
Acquired hemophagocytic lymphohistiocytosis /
Edinsel hemofagositik lenfohistiyositoz, 103
Intravenous immunoglobulin / İntravenöz immunoglobulin, 103
Adenovirus-associated hemophagocytic lymphohistiocytosis /
Adenovirus ilişkili hemofagositik lenfohistiyositoz, 103
Gaucher disease / Gaucher hastalığı, 307
Hemophagocytic lymphohistiocytosis /
Hemafagositik lenfohistiositozis, 307
Hepatosplenomegaly / Hepatosplenomegali, 307
Hemophagocytosis / Hemofagositoz, 309
Preterm / Prematüre, 309
Toxoplasma gondii / Toxoplasma gondii, 309
Hemophilia
Hemophilia A / Hemofili A, 17,101
Inhibitor formation / İnhibitör oluşumu, 17
F8 gene mutation / F8 gen mutasyonu, 17
Single nucleotide gene polymorphisms /
Tek Nükleotid Gen Polimorfizmleri, 17
Interleukins/cytokines/ İnterlökinler/sitokinler, 17
Association study / İlişkilendirme çalışması, 17
Newborn / Yenidoğan, 101
Liver / Karaciğer, 101
Hemorrhage / Hemoraji, 101
Postnatal hemorrhagic shock /
Doğum sonrası hemorajik şok, 101
Bleeding / Kanama, 101
Factor VIII deficiency / Faktör VIII eksikliği, 194
Acquired / Kazanılmış, 194
Immunosuppressive / Immunsupresif, 194
Hemophilia B / Hemofili B, 226
Factor IX / Faktör IX, 226
Mutation / Mutasyon, 226
Intron 3 / İntron 3, 226
mRNA splice site / mRNA eklenme bölgesi, 226
Acquired hemophilia / Kazanılmış hemofili, 434

Immune Thrombocytopenic Purpura
Thrombocytopenia / Trombositopeni, 32
Long-term survival / Uzun dönem takip, 32
Children / Çocuk, 32
Cerebral infarction / Serebral enfarkt, 184
Idiopathic thrombocytopenic purpura /
İdyopatik trombositopenik purpura, 184
Triple X syndrome / Triple X sendromu, 184
Iron Disorder
Anemia / Anemi, 61
Hepcidin / Hepsidin, 394
Insulin resistance / İnsülin direnci, 61
Iron overload / Demir yükü, 394
Inflammation / İnflamasyon, 61
Obesity / Obezite, 61
Leukocyte
Leukocyte populations / Lökosit popülasyonu, 49
C-reactive protein / C-reaktif protein, 49
Febrile children / Ateşli çocuk, 49
Lymphoma
Lymphoma / Lenfoma, 92,188
Chronic myeloid leukemia / Kronik myeloid lösemi, 92
Secondary malignancy / Sekonder malignite, 92
Adrenal glands / Adrenal bez, 188
Addisonian crisis / Addison krizi, 188
Non-Hodgkin lymphoma / Non-Hodgkin lenfoma, 205,207,403
Lymphoid cells neoplasms / Lenfoid hücreler tümörler, 205
B-Cell neoplasms / B-Hücre tümörleri, 205,207
Pharmacotherapeutics / Farmakoterapötikler, 207
Cytogenetics / Sitogenetik, 290
Non-Hodgkin’s lymphoma / Hodgkin dışı lenfoma, 290,381
Other lymphoproliferative diseases /
Diğer lenfoproliferatif hastalıklar, 290
Other leukemias / Diğer lösemiler, 290
Primary renal lymphoma / Primer renal lenfoma, 315
Follicular lymphoma / Foliküler lenfoma, 315
Treatment option / Tedavi seçeneği, 315
Primary adrenal non-Hodgkin lymphoma /
Primer adrenal non-Hodgkin lenfoma, 332
Central nervous system / Merkezi sinir sistemi, 332
Prognosis / Prognoz, 332
Therapy / Terapi, 332
Vincristine / Vinkristin, 337
Neuropathy / Nöropati, 337
Vocal cord paralysis / Vokal kord paralizi, 337
Paralytic ileus / Paralitik ileus, 337
Chemokines / Kemokinler, 381
Cytokines / Sitokinler, 381
Lymphocytes / Lenfositler, 381
Th2 pathway / Th2 yolağı, 381
Adult T-cell leukemia/lymphoma /
Erişkin T-hücreli lösemi/lenfoma, 424
Mogamulizumab / Mogamulizumab, 424
Hemodialysis / Hemodiyaliz, 424
CCR4 / CCR4, 424
HTLV-1 / HTLV-1, 424
Intravascular large B-cell lymphoma /
İntravasküler büyük B hücreli lenfoma, 403
Prostate / Prostat, 403
Non-germinal center B-cell / Non-germinal merkez B hücre, 403
Multiple Myeloma
Multiple myeloma /
Multiple myeloma, 84,136,231,374,388,428,435,437
LDH / LDH, 84
Prognosis / Prognoz, 84
Renin-angiotensin system / Renin-anjiotensin sistemi, 136
Progenitor cell / Progenitör hücre, 136
CD34+ / CD34+, 136
Drug resistance / İlaç direnci, 231
Cell cycle / Hücre döngüsü, 231
Apoptosis / Apoptoz, 231
HLA-A / HLA-A, 388
HLA-B / HLA-B, 388
HLA-DRB1 / HLA-DRB1, 388
Genetic susceptibility / Genetik yatkınlık, 388
Bone-specific alkaline phosphatase /
Kemik Spesifik Alkalen Fosfataz, 374
Bortezomib / Bortezomib, 374
Thalidomide / Talidomid, 374
Unusual morphology / Olağan dışı morfoloji, 437
Skin / Deri, 435
Necrobiotic / Nekrobiyotik, 435
Xanthogranuloma / Ksantogranüloma, 435
Lymphoproliferative Disorders
Renal transplantation / Böbrek nakli, 79
Post-transplant lymphoproliferative disease/
Posttransplant lenfoproliferatif hastalık, 79
Lymphoma / Lenfoma, 79
Immunosuppression / İmmünsupresyon, 79
Rituximab / Rituksimab, 79
Abnormal karyotype / Anormal karyotip, 79
Mutation
Myeloproliferative disorders / Miyeloproliferatif hastalıklar, 239
Myeloproliferative neoplasm / Myeloproliferatif neoplasm, 239
Essential thrombocythemia / Esansiyel trombositemi, 239
Polycythemia vera / Polisitemia vera, 239
Primary myelofibrosis / Primer myelofibrozis, 239
JAK2V617F mutation / JAK2V617F mutasyonu, 239
Bone marrow histopathology / Kemik iliği histolojisi, 239
Red cell mass / Kırmızı kan hücresi kitlesi, 239
Erythrocyte count / Kırmızı kan hücresi sayısı, 239
Myelodysplasia
Myelodysplasia / Miyelodisplazi, 394
Myeloproliferative Disorders
Myeloproliferative disorders /
Miyeloproliferatif hastalıklar, 121,239
Endothelial cell protein C receptor /
Endotelyal protein C reseptörü, 121

Thrombosis / Tromboz, 121
Myeloproliferative neoplasm / Myeloproliferatif neoplasm, 239
Essential thrombocythemia / Esansiyel trombositemi, 239
Polycythemia vera / Polisitemia vera, 239
Primary myelofibrosis / Primer myelofibrozis, 239
JAK2V617F mutation / JAK2V617F mutasyonu, 239
Bone marrow histopathology / Kemik iliği histolojisi, 239
Red cell mass / Kırmızı kan hücresi kitlesi, 239
Erythrocyte count / Kırmızı kan hücresi sayısı, 239
Plasmacytoma
286-Solitary Bone Plasmacytoma Progressing into Retroperitoneal
Plasma Cell Myeloma with No Related End Organ or Tissue
Impairment: A Case Report and Review of the Literature
Solitary bone plasmacytoma / Soliter kemik plazzmasitoması, 286
Retroperitoneal plasma cell myeloma /
Retroperitoneal plazma hücreli myeloma, 286
Related end organ or tissue impairment /
İlişkili organ ya da doku disfonksiyonu, 286
Bone marrow plasmacytosis / Kemik iliği plazmasitozu, 286
Extramedullary myeloid tumor / Extramedüller miyeloid tümör, 295
Pancreas / Pankreas, 295
Allogeneic stem cell transplantation /
Allogeneik kök hücre nakli, 295
Platelet Disorders
Blood cell count / Kan hücresi sayımı, 107
Blood platelets / Kan trombositleri, 107
Blood platelet disorders / Kan trombosit bozuklukları, 107
Peripheral blood smear / Periferik kan yayması, 107
Paroxysmal Nocturnal Hemoglobinuria
SLE / SLE, 323
CD55 / CD55, 323
CD59 / CD59, 323
PNH / PNH, 323
Pure Red Cell Aplasia
Lenalidomide / Lenalidomid, 99
PRCA / PRCA, 99
MSD/ MDS, 99
Radiotherapy
Castleman’s disease / Castleman hastalığı, 197
Radiotherapy / Radyoterapi, 197
Unicentric / Unisentrik, 197
Red Cell Membrane Disorder
RBC / Eritrosit, 25
Membrane disorders / Zar bozuklukları, 25
Band 3 / Band 3, 25
Flow cytometry / Akım sitometri, 25
Sickle Cell
Sickle cell disease / Orak hücre hastalığı, 255
Inflammation / Enflamasyon, 255
Cytokine / Sitokin, 255
TNFSF15 gene / TNFSF15 geni, 255
Stem Cell Transplantation
Granulocytic sarcoma / Granülositik sarkom, 88
Breast / Meme, 88
Stem cell transplantation / Kök hücre nakli, 88
18FDG-PET/CT / 18FDG-PET/CT, 88
Epstein-Barr virus / Epstein-Barr virüs, 155
Parvovirus B19 / Parvovirus B19, 155
Allogeneic stem cell transplantation /
Allojenik kök hücre transplantasyonu, 155
Real-time PCR / Gerçek zamanlı PCR, 155
Cytomegalovirus reactivation /
Sitomegalovirüs reaktivasyonu, 276
Human leukocyte antigens / İnsan lökosit antijeni, 276
Allogeneic stem cell transplantation /
Allojeneik kök hücre nakli, 276
Graft-versus-host disease / Graft versus host hastalığı, 276
Prognosis / Prognoz, 276
CMV scoring index / CMV skorlama indeksi, 276
Thalassemia
Thalassemia / Talasemi, 5
Thalassemia intermedia / Talasemi intermedya, 5
Iron chelation / Demir şelasyonu, 5
Ineffective erythropoiesis / İnefektif eritropoez, 5
Iron overload / Demir yükü, 5
Beta-thalassemia / Beta-talasemi, 272
C282Y mutation / C282Y mutasyonu, 272
Hemochromatosis / Hemokromatozis, 272
Thalassemia intermedia / Talasemi intermedia, 311
Leukemia / Lösemi, 311
Cancer / Kanser, 311
β-Thalassemia minor / β-Talasemi minor, 363
Bcl-2 / Bcl-2, 363
Apoptosis / Apoptoz, 363
Thymus / Timüs, 417
Blood transfusion / Kan Transfüzyonu, 417
Beta-thalassemia / Beta talasemi, 417
Iron overload / Demir yüklenmesi, 417
Tymic lndex / Timik indeks, 417
Thrombosis
P-selectin polymorphisms / P-selektin polimorfizmleri, 357
Thrombosis / Tromboz, 357
Antiphospholipid syndrome / Antifosfolipid sendrom, 357
Thrombotic Thrombocytopenic Purpura
216-Atypical Hemolytic Uremic Syndrome: Differential
Diagnosis from TTP / HUS and Management
Atypical hemolytic uremic syndrome (aHUS) /
Atipik hemolitik üremik sendrom (aHÜS), 216
Thrombotic thrombocytopenic purpura (TTP) /
Trombotik trombositopenik purpura (TTP), 216

Eculizumab / Eculizumab, 216
TTP/HUS/TTP / HUS, 216
Thrombotic microangiopathy (TMA) /
Trombotik mikroanjiopati (TMA), 216
ADAMTS13 / ADAMTS13, 216
Transfusion
Duffy phenotyping / Duffy fenotiplendirme, 367
Kidd phenotyping / Kidd fenotiplendirme, 367
Genotyping / Genotiplendirme, 367
Multitransfused patients / Çoklu transfüzyon alan hastalar, 367
Treatment
Myocardial infarction after rituximab /
Rituximab’den sonra myokard infarktı, 95
Posterior reversible encephalopathy syndrome (PRES) /
Arka geri dönüşümlü ensefalopati sendromu (PRES), 109
Methotrexate / Metotreksat, 109
Magnetic resonance imaging / Manyetik rezonans görüntüleme, 109
Fluidattenuated inversion recovery /
Sıvı zayıflatılmış dönüşüm kazanımı (FLAIR), 109
Invasive fungal infection / İnvazif fungal infeksiyonlar, 111
Antifungal treatment / Antifungal tedavi, 111
Evidence / Kanıt, 111
Hematological malignancies / Hematolojik malignansi, 111
Other
Turkish Journal of Hematology: From “Istanbul Contribution to
Clinical Science” to “Pubmed Central”, 1
Posterior reversible encephalopathy syndrome (PRES) /
Arka geri dönüşümlü ensefalopati sendromu (PRES), 109
Methotrexate / Metotreksat, 109
Magnetic resonance imaging /
Manyetik rezonans görüntüleme, 109
Fluidattenuated inversion recovery /
Sıvı zayıflatılmış dönüşüm kazanımı (FLAIR), 109
Blood / Kan, 161
Blood component / Kan ürünü, 161
Wastage / İsraf, 161
Transfusion / Nakil, 161
Blood bank / Kan bankası, 161
Erythrocyte deformability / Eritrosit deformabilitesi, 168
RhoA / RhoA, 168
Rho-kinase / Rho-kinaz, 168
Y-27632 / Y-27632, 168
Fasudil / Fasudil, 168
Lysophosphatidic acid / Lizofosfatidik asit, 168
C3 / C3, 168
Cerebral infarction / Serebral enfarkt, 184
Idiopathic thrombocytopenic purpura /
İdyopatik trombositopenik purpura, 184
Triple X syndrome / Triple X sendromu, 184
Castleman’s disease / Castleman hastalığı, 197
Radiotherapy / Radyoterapi, 197
Unicentric / Unisentrik, 197
Thrombocytopenia / Trombositopeni, 199
Kawasaki disease / Kawasaki hastalığı, 199
Aneurysm / Anevrizma, 199
Acute lymphoblastic leukemia / Akut lenfoblastik lösemi, 203
Isolated breast relapse / İzole meme nüksü, 203
Hematologic manifestations of systemic diseases /
Sistemik hastalıkların hematolojik belirtileri, 211
Lymphoid cells neoplasms / Lenfoid hücreler tümörleri, 211
Bone marrow failure / Kemik iliği yetmezliği, 211
Hypocalcemic seizure / Hipokalsemik nöbet, 336
Infantile malign osteopetrosis / Malign infantil osteopetrosis, 336
TCIRG1 gene mutation / TCIRG1 gen mutasyonu, 336
Cyclosporine / Siklosporin, 432
Toxicity / Yan etki, 432
Stem cell transplantation / Kök hücre nakli, 432
Allograft / Allogreft, 430
Extracorporeal photopheresis / Ekstrakorporeal fotoferez, 430
Heart transplantation / Kalp transplantasyonu, 430
Quilty effect / Quilty etkisi, 430
Rejection / Rejeksiyon, 430
Crystalline inclusion bodies / Kristal inklüzyon cisimcikler, 428
Gaucher cells / Gaucher hücreleri, 428
Multiple myeloma / Multiple miyeloma, 428
Humoral immune response / Hümoral immün yanıt, 420
Immunodeficiency diseases / İmmün yetmezlikler, 420
Immune response disorder / İmmün yanıt bozukluğu, 420
Immunoglobulins / İmmünglobulinler, 420
Hyper IgM syndrome / Hiper IgM sendromu, 420
CD40L / CD40L, 420

31 st Volume Index / 31. Cilt Dizini
AUTHOR INDEX - YAZAR DİZİNİ
2014
A. Muzaffer Demir.............. 111,321
A1i Taher.........................................5
Abbas Behzad- Behbahani.............25
Abbas Hajifathali.........................388
Abdülkerim Yıldız.......................323
Adalet Meral Güneş......................32
Adnan Şimşir...............................403
Ahmet Ata Özçimen....................255
Ahmet Emre Eşkazan..................374
Ahmet Koç..................................417
Ahmet Özet.................................207
Aiste Savukaityte.........................367
Ajay Gogia............................. 95,203
Akın Uysal.....................................79
Alev Erikçi.....................................75
Alexandra Agapidou...................422
Ali Ayçiçek..................................417
Ali Fettah.....................................336
Ali Uğur Ural...............................231
Alişan Yıldıran.............................420
Alpay Azap..................................342
Altay Atalay.................................155
Amirhossein Emami....................149
Amr Radwan...................................5
Ana Cvetanovic...........................315
Anıl Kumar N................................56
Anthony Haddad.............................5
Aptullah Haholu...........................75
Arbil Açıkalın...................... 205,295
Arezou Sayad...............................388
Arturas Inciura............................367
Arzu Akçay..................................311
Asit Mridha.................................286
Aslıhan Karul..............................363
Asmae Quessar............................408
Asu Fergün Yılmaz......................403
Atahan Çağatay...........................111
Aydan İkincioğulları...................420
Ayfer Çolak.................................319
Ayhan Dönmez............................403
Ayhan Gazi Kalaycı.....................420
Aylin Heper.................................430
Aynur Küçükcongar......................49
Aynur Uğur Bilgin.......................194
Ayşegül Ünüvar............ 212,311,325
Ayşegül Verim.............................301
Ayşegül Zenciroğlu.....................101
Ayşenur Bahadır............................68
Ayşenur Öztürk...........................317
Aytemiz Gürgey..............................1
Ayten Bilir...................................261
Bahattin Tunç...................... 336,432
Bahoush Gholamreza..................307
Balkis Meddeb.............................188
Banu Aydın..................................101
Banu Sarsık..................................403
Barış Malbora...................... 101,103
Barış Naiboğlu.............................301
Begüm Şirin Koç................. 212,325
Bengü Timoçin................................1
Berna Bozkurt Duman................205
Berna Totan Ateş.........................197
Beyza Ener...................................342
Birol Baytan...................................32
Branimir Spassov...........................40
Bülent Çetin................................207
Bülent Eser..................................155
Bülent Güzel...............................417
Bülent Kantarcıoğlu....................411
Bülent Orhan...............................207
Bülent Zülfikar..............................17
Burak Erer...................................357
Burak Toprak..............................319
Burak Uz.....................................136
Burçin Beken....................... 199,210
Burcu Fatma Belen......................399
Burhan Ferhanoğlu.....................374
Cafer Adıgüzel............................411
Can Boğa.....................................180
Cansın Tulunay Kaya..................430
Cem Atabey...................................75
Cengiz Beyan...............................107
Cengiz Ceylan.............................319
Çetin Erol....................................430
Chang-Kun Lin...........................226
Christina Chadjiaggelidou..........422
Chun-Lian Jin.............................226
Çiğdem Aliosmanoğlu................313
Çiğdem Tepe Karaca...................301
Çiğdem Usul Afşar.............. 197,205
Cüneyt Müderrisoğlu....................61
Dalia Abdel Raouf.......................143
Danguole Raulinaityte................367
Debdatta Basu.............................175
Deniz Gören Şahin......................428
Deniz Teke....................................84
Deniz Tuğcu................................311
Derya Özyürük............................417
Derya Sağlam..............................155
Diana Remeikiene.......................367
Didem Atay.................................215
Didem Torun...............................317
Dilek Dilli....................................101
Dilek Erdem................................381
Dimitra Markala..........................422
Dina Ahmed Mehaney................394
Doaa Shahin................................128
Doğuş Vurallı................................49
Dong-Hua Cao............................226
Duran Karabel.............................313
Düzgün Özatlı.............................381
Ebru Koca...................................121
Ebru Sarıbeyoğlu.........................311
Elham Jaberi................................149
Elham Roshandel........................388
Elif Çalış......................................197
Elif Ezgi Üstün............................430
Elif Gülsüm Ümit........................321
Elif Suyanı...................................323
Elona Juozaityte..........................367
Emad Azmy.................................143
Emine Bağır.................................197
Emine Dibek Mısırlıoğlu.............432

Emine Türkkan...........................215
Emre Tekgündüz...........................92
Ender Ülgen..................................61
Engin Kelkitli...................... 201,381
Engin Yenilmez.............................68
Enver Öte....................................290
Ercan Kaya..................................338
Erdem Dağlıoğlu.........................417
Eren Gündüz.................. 88,338,428
Erika Skrodeniene.......................367
Erkut Erkurt................................197
Erol Ayyıldız................................194
Esma Altunoğlu............................61
Ezgi Uysalol........................ 212,325
Fabian Tarin................................436
Farzaneh Aboualizadeh.................25
Fatemeh Samiee Rad...................161
Fatih Mehmet Azık.....................432
Fatma Akyol................................319
Fatma Gümrük............. 199,210,272
Fatma Nur Sarı............................309
Ferda özbay Hoşnut....................103
Feride İffet Şahin.........................290
Feryal Karaca...............................197
Fevzi Altuntaş...............................92
Fezan Şahin Mutlu......................261
Fibo Ten Kate..............................239
Figen Atalay................................121
Figen Başaran Demirkazık..........342
Figen Kuloğlu.............................321
Figen Özçay................................103
Filiz Karagöz...............................420
Francisco de Paz.........................436
Funda Pepedil Tanrıkulu............411
Füsun Erdenen..............................61
Gargi Tikku.................................286
Ghasem Miri-Aliabad..................106
Gökhan Kuş................................261
Gökhan Metan............................342
Gökhan Sargın.................... 192,363
Gueorgui Balatzenko.....................40
Gülendam Bozdayı......................276
Gülşah Kaygusuz..........................79
Gülsan Türköz Sucak.......... 276,323
Gülsüm Kadıoğlu Şimşek...........309
Gülyüz Öztürk............................325
Günay Balta.................................272
Gupta Shweta..............................341
Gürbey Soğut..............................430
Gürhan Kadıköylü.............. 192,363
Güven Çetin................................374
Güven Yılmaz..............................411
Habib Alah Golafshan...................25
Hakan Göker...............................136
Hakan Özdoğu.................... 180,295
Halil Uğur Hatipoğlu..................426
Halis Akalın.................................111
Hamdi Akan..................... 1,111,342
Hamdi Cihan Emeksiz..................49
Hanjun Kim................................184
Hasan Alaçam.............................381
Hasan Celalettin Ümit.................321
Hasan Mücahit Özbaş.................438
Hasan Suat Arslantaş...................197
Hasibe Gökçe çınar.....................101
Hava Üsküdar Teke............... 84,428
Hayam Fathi Ghazi.....................128
Hela Ben Abid.............................188
Hendrik De Raeve.......................239
Hilmi Atay...................................381
Hong-Gui Xu..............................266
Hüseyin Göksülük......................430
Hüseyin Gümüş..........................417
Hüseyin Kemal Türköz...............411
Hüseyin Kılıç...............................155
İbrahim C. Haznedaroğlu...........136
İdris Kandemir............................155
İdris Yücel...................................381
İlknur Kozanoğlu........................180
İlknur Sivrikoz Ak.........................88
İnanç Değer Fidancı......................17
İpek Durusu....................................1
İrfan Yavaşoğlu.................... 192,363
Işık Kaygusuz Atagündüz...........411
Işınsu Kuzu...................................79
Itır Şirinoğlu Demiriz....................92
Ivan Petkovic...............................315
Ivica Pejcic..................................315
Jain Prantesh...............................341
Jan Jacques Michiels....................239
Ji-Yong Lee..................................184
Jian-Pei Fang...............................266
Jin-biao Zhang.............................328
Jing-Li.........................................328
Jing-Li Sun..................................226
Jose Verdu...................................436
Juwon Kim..................................184
Kaan Kavaklı.................................17
Kadir Acar...................................276
Kai Mu.........................................226
Kanay Yararbaş............................319
Kansu Büyükafşar.......................168
Kap Jun Yoon..............................184
Karima Kacem.............................188
Kenan Keven.................................79
King H. Lam................................239
Kubilay Ekiz................................201
Kübra Bölük................................215
Kürşat Kaptan.............................107
Lakshmaiah K Chinnagiriyappa....56
Lamia Aissaoui............................188
Leili Moezzi...................................25
Levent Yıldız....................... 201,381
Leyla Ağaoğlu...................... 311,325
Leylagül Kaynar..........................155
Li-juan Jia....................................328
Lu-Hong Xu................................266
M. Cem Ar........................ 17,61,374
Mahmut Civilibal........................426
Mahmut Kebapcı.........................338
Mahmut Yeral..............................180
Mahshid Mehdizadeh..................388
Maitreyee Bhattacharyya...............99
Makoto Fukuda...........................424
Malina Romanova.........................40
Margarita Guenova.......................40
Mari Yoshihara............................424
Maria Jimenez Esteso..................436
Maria Tzimou..............................422
Mehmet Halil Celiksoy...............420
Mehmet Kanbay............................84
Mehmet Sönmez.........................438
Mehmet Turgut................... 201,381
Mehmet Yekta Öncel...................309
Mehran Karimi..............................25
Melek Ergin.................. 197,205,295
Melike Sezgin Evim.......................32
Meltem Ceyhan Bilgici................420
Meltem Olga Akay................ 88,261
Memiş Hilmi Atay.......................201
Meral Günaldı..................... 205,295
Merih Kızıl Çakar.......................323
Meryem Albayrak........................399
Miljan Krstic...............................315
Mina Bahrololoumi
Shapourabadi..............................149
Mine Kadıoğlu..............................68
Miri-Aliabad Ghasem..................307
Mirjana Balic...............................315
Mirjana Todorovic.......................315
Mohamad Mehdi
Daneshi Kohan............................161
Mohamed Abd
El Kader Morad...........................394
Mohamed Sabry..........................143
Mohammad Mohammadi...........149
Mohammad Reza
Khorramizadeh...........................149
Mohammad Taghi Akbari...........388
Mojtaba Tabatabaei Yazdi...........149
Monica Jain.................................286
Mualla Çetin...............................199
Müge Gökçe................................311
Müge Sayitoğlu...........................136
Muhit Özcan...............................194

Murat Elevli................................426
Murat İnanç.................................357
Murat Kutlay.................................75
Murat Söker................................313
Müsemma Karabel......................313
Mustafa Başak...............................84
Mustafa Çetin..............................155
Mustafa Karagülle................. 88,428
Mustafa N. Yenerel......................216
Mutlu Arat............................. 79,111
Nadia El-Menshawy............ 128,143
Naghmeh Rajaei..........................149
Naji Mallat.......................................5
Nalan Akyürek............................399
Namık Özbek...................... 103,432
Namratha N. Rajkumar.................56
Nazan Özsan...............................403
Necmiye Canacankatan..............255
Neda Setayesh.............................149
Nejat Akar............................. 97,317
Neşe Saltoğlu...............................111
Neşe Yaralı........................... 309,336
Neslihan Andıç...........................428
Nikolay Stoyanov..........................40
Nil Güler.....................................381
Nilay Ermantaş............................438
Nilgün Kurucu..............................68
Nilgün Sayınalp...........................136
Nilgün Selçuk Duru....................426
Nilüfer Alpay...............................357
Noha M. El Husseiny..................394
Nurdan Uras................................309
Nurullah Okumuş.......................101
Oğuz K. Başkurt..........................168
Oğuz Kara...................................205
Olga Meltem Akay.............. 338,428
Ömer Bilaç..................................301
Ömer Devecioğlu......... 212,311,325
Ömrüm Uzun..............................342
Osman İ. Özcebe.........................136
Osman İlhan........................ 194,430
Özden Hatırnaz...........................136
Özden Yener Çakmak.................109
Özge Ağlamış..............................336
Özge Özer...................................290
Özgür Ulaş Özcan.......................430
Özkan Sayan.................................75
Özlem Özdemir Kumbasar.........342
Padhi Somanath..........................332
Pamir Işık....................................432
Paul Tyan........................................5
Pelin Mutlu.................................231
Penka Ganeva................................40
Pervin Topçuoğlu..........................79
Piltan Büyükkaya........................201
Prakas Kumar Mandal...................99
Prashant Mehta...........................203
Pritinanda Mishra.......................175
Quan-le Zhang............................328
R. Nalan Tiftik.............................168
Rafat Mohebbi Far.......................161
Raihane Ben Lakhal....................188
Raja Paramanik..................... 95,203
Rajesh Grover..............................286
Rajive Kumar..............................203
Rakhee Kar..................................175
Ramzi Ben Amor.........................188
Rasa Ugenskiene.........................367
Renata Simoliuniene...................367
Reyhan Diz-Küçükkaya..............357
Reza Ranjbaran.............................25
Rıdvan Ali...................................111
Sachin Khurana.............................95
Saeed Hashemi Bozchlou............149
Şahika Zeynep Akı......................276
Sahoo Jayaprakash......................332
Said Benchekroun.......................408
Salah Aref....................................143
Salih Aksu...................................136
Sami Zriba...................................188
Şamil Hızlı...................................103
Sandeep Saha.................................99
Sang Sun Hwang.........................184
Sara Erol......................................101
Sarjana Dutt..................................56
Seda Kibaroğlu............................109
Sedigheh Sharifzadeh....................25
Selami Koçak Toprak... 109,121,290
Selçuk Göçmen.............................75
Selma Gökahmetoğlu..................155
Selma Ünal.......................... 255,272
Selvi Kelekçi................................313
Sema Anak.......................... 212,325
Sema Arayıcı...............................309
Sema Karakuş..............................121
Semra Paydaş....................... 197,295
Şeniz Öngören Aydın.......... 111,374
Serap Işıksoy...............................428
Serap Karaman.................... 212,325
Serdar Beken...............................101
Şerife Efsun Antmen...................255
Server Hande Çağlayan.................17
Seval Kul.....................................168
Sevde Seçer..................................336
Sevgi Kalayoğlu-Beşışık...............111
Sevgin Taner................................336
Sevtap Arıkan Akdağlı................342
Şeyda Erdoğan.............................205
Seyyal Rota..................................276
Shahla Ansari..............................106
Shahrouz Sheidaii.......................301
Shinya Kimura............................424
Shyamali Dutta..............................99
Sibel Aşcıoğlu Hayran.................342
Şinasi Özsoylu.............................434
Sinem Civriz Bozdağ.....................92
Slavica Stojnev............................315
Sofia Marouane...........................408
Soheila Abedinpour....................388
Solafa El Sharawy........................143
Sophia Vakalopoulou..................422
Soumaya Anoun..........................408
Spiro Konstantinov.......................40
Sreeya Das...................................175
Stavri Toshkov..............................40
Stephan Borte..............................420
Sukhal Shashvat..........................341
Şule Mine Bakanay........................79
Şule Şengül....................................79
Şule Ünal............................. 199,210
Süleyman Durmaz.......................155
Suna Emir...................................432
Suzin Çatal Tatonyan..................136
Svetislav Vrbic.............................315
Tahereh Kalantari..........................25
Tamer Sayın................................430
Teoman Soysal............................374
Theodosia Papadopoulou...........422
Tihomit Dikov...............................40
Timur Tunçalı...............................79
Tiraje Celkan...............................426
Tomoya Kishi..............................424
Tufan Öge...................................261
Tülay Güler.................................109
Tülay Tecimer.............................207
Tülin Fıratlı Tuğlular..................411
Tuphan Kanti Dolai......................99
Turan Bayhan..............................432
Türkiz Gürsel........................ 49,399
Ufuk Can.....................................109
Ufuk Gündüz..............................231
Uğur Dilmen...............................309
Uğur Özbek.................................136
Ülker Koçak................................399
Umesh Das....................................56
Ümit Çobanoğlu.........................438
Vasil Hrischev...............................40
Vasileia Garypidou......................422
Vehbi Erçolak..............................205
Velat Şen......................................313
Veysel Haksöyler.........................295
Veysel Kutay Vurgun...................430
Veysel Sabri Hançer.....................357
Vishwanath Sathyanarayanan.......56
Visweswariah Lakshmi Devi.........56

Walid Bouteraa............................188
Wei-min Li..................................328
Wen-Jun Weng............................266
Wilfried Schroyens......................239
Xiang-Wei Ma.............................226
Xiao-Li Liu..................................226
Xiao-Zhong Bai...........................226
Yahya Büyükaşık.........................136
Yasushi Kubota...........................424
Yeşim Oymak..............................417
Yıldız Aydın.................................374
Yosr Ben Abdennebi....................188
Young Uh....................................184
Yousefian Saeed...........................106
Yuan-kai Bo.................................328
Yücel Erbilgin.............................136
Yuji Ikeda....................................424
Yüksel Bek...................................381
Yurdanur Kılınç............................17
Zafer Başlar............................ 17,374
Zafer Gülbaş................................338
Zaher Belhadj Ali........................188
Zahit Bolaman..................... 192,363
Zahra Abdolazimi........................161
Zargham Sepehrizadeh...............149
Zekaver Odabaşı..........................342
Zerrin Yılmaz..............................290
Zeynep Karakaş............ 212,311,325
Zübeyde Nur Özkurt..................276
Zühre Kaya............................ 49,399
Zwi Berneman.............................239

Advisory Board of This Issue (December 2014)
Ahmet Emre Eşkazan, Turkey
Ahmet Muzaffer Demir, Turkey
Alexandra Agapidou, Greece
Ayşegül Ünüvar, Turkey
Ben E. de Pauw, the Netherlands
Burhan Turgut, Turkey
Canan Albayrak, Turkey
Davut Albayrak, Turkey
Deniz Yılmaz Karapınar, Turkey
Duran Canatan, Turkey
Erol Erduran, Turkey
Fahir Özkalemkaş, Turkey
Fahri Şahin, Turkey
Fatma Gümrük, Turkey
Ferit Avcu, Turkey
Fevzi Altuntaş, Turkey
Harika Okutan, Turkey
Ioannis Kotsianidis, Greece
Işınsu Kuzu, Turkey
Klara Dalva, Turkey
Mahmut Bayık, Turkey
Marek Sanak, Poland
Maria Papaioannou, Greece
Mehmet Yılmaz, Turkey
Meletios Dimopoulos, Greece
Meliha Nalçacı, Turkey
Meral Beksaç, Turkey
Mounia Bendari, France
Mualla Çetin, Turkey
Murat Akova, Turkey
Mustafa Ünübol, Turkey
Mutlu Arat, Turkey
Namık Özbek, Turkey
Nazan Sarper, Turkey
Nükhet Tüzüner, Turkey
Olga Meltem Akay, Turkey
Owen J McGinn, United Kingdom
Özgür Mehtap, Turkey
Reyhan Diz Küçükkaya, Turkey
Rıdvan Ali, Turkey
Selami Koçak Toprak, Turkey
Semra Paydaş, Turkey
Shigeki Takemoto, Japan
Şule Ünal, Turkey
Türkan Patıroğlu, Turkey
Zühre Kaya, Turkey