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Newsletter Vol 3 issue 2, Nov 2012

Dear colleagues,

I hope you all enjoyed Diwali with true glow of our eternal lights, which is so necessary for our profession. In this issue I can say with pride that we at Lotus, performed our first stem cell transplant for thalassaemia patient, who was a 5 year old girl from IRAQ. Yes, this was our first case of medical tourism!

As usual I will also present a case vignette so as to learn new things in Haematolog y and Oncology.

Case 1:    5 year old Iraqi girl with thalassaemia major.

She was referred to Lotus Institute of Stem cell transplantation for stem cell transplant, as this is the only curative treatment for the disease. She had been regularly transfused since the age of 6 months. Her 8 year old brother was fortunately HLA matched (we have to do special tests to see if the sibling is a match, just blood group matching is not important and enough).

Step 1: Preparation of the patient for transplant:  we give chemotherapy to “empty” the bone marrow and “create” space for the new stem cells. We used the latest Italian protocol for the same. This takes 7 days.

Step 2: Harvesting the stem cells from the donor:  we give special “growth factor injections” G-CSF (Colony “stem cell” stimulating factors) 4 days prior to the proposed date of transplant to the donor. His bone marrow stem cells are “directed” to the peripheral blood and then “harvested” on an apheresis machine (like we harvest platelets for single donor platelets).

Step 3: wait and watch for the “new” stem cells as they establish themselves in the “new body”. We give stem cells harvested from the donor through a central line like the way we give blood transfusion. The new cells took 13 days to establish in new body and then they started to produce new red cells, white cells and platelets.

What can go wrong?   Transplant is a complicated procedure and utmost care has to be taken to prevent complications:

  1. The patient was nursed in special “Bone Marrow Transplant” room which we have at Lotus Institute. All the medical and paramedical staff are trained for the same. This prevents serious infection.
  2. The stem cells can be “rejected” by the recipient, so we give anti-rejection medicines like cyclosporine for atleast 6 months.
  3. The new stem cells can “attack” the recipients liver cells and skin leading to “graft versus host disease”. We also give special medications to prevent the same.
  4. 30 days post the transplant we did “chimerism analysis” to see the percentage of the donor cells in the recipient and I am glad to declare it is 100% (this is the true measure of the success of the transplant).
  5. This girl will never need blood transfusion now and will lead a normal life.

Case 2: Case of Pyrexia of unknown origin (PUO) referred by Dr Vijay Patil, Amalner, Dist: Jalgaon.

43 Yr old female was referred to me for persistent fever and leucocytosis. She had fever for 3 months for atleast 5 days a week. She also complained of back ache. She lives in a semi rural setting in Amalner. Before being referred to me, she was referred to Mumbai and was extensively worked up with Bone Marrow and special tests for leukemia. No diagnosis could be reached. On examination: she use to have rash (macular) on and off. No hepatosplenomegaly and lymphadenopathy.

Diagnosis: Brucellosis. Brucella IgM analysis was strongly positive.

Treatment: 6 week course of doxycycline, rifampicin and levofloxacin was given and her fever and leucocytosis settled.

Take home message:

  1. PUO should be investigated thoroughly and diagnosis should be reached with minimum possible investigations.
  2. Leucocytosis or neutrophilia with no fever should not be given “blind” antibiotics.
  3. Geographical location and detailed history should be taken to reach an early diagnosis.

LOTUS Diagnostics:  New test launch.

Keeping with recent times and the fact that dengue fever is rampant and is here to haunt us we have started “Dengue NS 1 antigen test by ELISA” method. This is more sensitive and specific then the current NS1 antigen method which is done by chromatography method. The new test is not “observer” dependent and eliminates false positives. This test will enable us all to make a proper and early diagnosis of Dengue fever.  We have also installed “ Nephlometry” machine where we do special tests for immunodeficiency Like immunoglobulin levels, C3 and C4 for autoimmune disease etc. Dr Subhash Junagade who heads LOTUS diagnostics is as usual very " strict” and makes sure ours is not a “technician” lead laboratory.

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