Happy new year to all my colleagues and seniors,

I hope this New Year has started for all of you as you have planned. I am sure with rising cases of COVID 19 new variants – you all are taking care of yourself, your dear ones and patients.

We will continue our newsletter series into the 2nd year. I thank you all for the feedback on our previous newsletters. Learning is continues process and that is the beauty of practicing medicine! Each case has the potential to teach us if we want to. In this newsletter I am going to discuss a case of pancytopenia due to aplastic anemia.

Case –

Miss KK, a 22 yrs female, was admitted at Majalgaon with a Hb of 2.3 and very low platelet count leading to heavy menstrual bleeding. She was managed as an emergency with blood and platelet transfusion and referred very next day to Jeevan Amrut considering CBC showing a TLC count of 1170 with 80% lymphocytes for further evaluation and management. Her bone marrow aspirate revealed hypocellular marrow particles with less than 5 % cellularity. She got admitted same day. Bone marrow biopsy also confirmed the diagnosis. Chromosomal breakage study to rule out fanconis aemia – came negative, her paroxysmal Nocturnal Haemoglobinurea (PNH) work up showed no evidence of CD 55 and CD 59 positive cells on FLAIR. PNH and fanconis work up are important in every young case of aplastic anemia for making treatment decisions. She was discharged on Cyclosporin, Danazol and Eltrombopag. Family counselled regarding option of BMT or Anti thymocyte globulin (ATG).

Eltrombopag is a thrombopoietin receptor agonist used to treat thrombocytopenia or aplastic anemia.

Treatment –

In 2 weeks’ time she got admitted for ATG – which was given over 4 days and costing around 4.0 lakh Rs. After that she continued on Cyclosporin and Eltrombopag (Thrombopoitin analogue ) for 3 months with 2 weekly follow up and sos blood product transfusion support. At 4 months from diagnosis her blood counts are almost normal and she is off all transfusions. She continues to be on Cyclosporin for at least 1 year.

Antithymocyte Globulin (ATG) – Indian origin Brand – Bharat Serum

Learning points –

  1. Aplastic anemia is far more common in India as compare to the west.
  2. It is a life threatening disease mostly affecting young population. Most common reason for death is bleeding or infection – with delay in diagnosis.
  3. Initial presentation is Pancytopenia with – fever/Infection/bleeding/non healing ulcers/severe anemia. Sometimes hepatitis. If initial CBC showing pancytopenia with profound lymphocytosis – early diagnosis with marrow biopsy is important.
  4. Early referral to haematology and neutropenic care – can save many lives. Initial days in ICU and blood transfusion support, most of the times lead to financial drying of family, making life saving treatment decisions unavailable.
  5. With availability of medicines like Antithymocyte globulin (ATG), Eltrombopag and Bone marrow transplants – prognosis of these patients has significantly improved recently.
  6. ATG, Cyclosporin and Eltrombopag (ACE Protocol) – recent studies show up to 90 % patient survival.  

Haematology News from across the world –

Watch this interesting video about CAR-T cell therapy and its role in various malignancies.


Jeevan Amrut News

Dr Abhishek Zanwar, DM in Rheumatology and Immunolgy is available with his services at Jeevan Amrut Haematology Center since last more than 3 years. In his recent visit he had a marathon OPD with more than 100 superspeciality consultations spanning over 12 hours.

He is Available every month – First Friday – from 9 AM to 6 PM.

Dr Abhishek Zanwar – Consultant Rheumatologist and Immunologist, Ruby Hall Clinic, Pune. Contact No . 9699507339

Seeking your blessings.

Thank you

Dr Manoj Toshniwal –

Contact No – 9225300842


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