Clinicohaematological profile of aplastic anaemia in BRIMS, Teaching Hospital, Bidar

Objectives: There is a scarcity of clinical data in the field of aplasitc anaemia from rural India. Present study was conducted in BRIMS, Teaching Hospital, Bidar to find out the clinicohaematological profile and the possible aetiological factors in patients with aplastic anemia. Methodology: The study population (n=100) included 25 children with male to female ratio 4.93:1. weakness was present in all cases and pallor was present in 74.70% cases. Fever, bleeding episodes and localized infection were found in 55.42%, 48.19% and 27.71% cases respectively. There was no difference in clinical manifestation between children and adult except occurrence of fever (p=0.0365). Results: We identified possible aetiological factors in 32.53% cases as relevant drug intake in 10.84%, exposure of chemicals in 13.25% and hepatitis in 8.43% cases. We found low mean haemoglobin (3.811.71g/dl), leucocyte and platelet (3.051.3 and 37.3035X103/ cmm, neuytrophil (30.2821.76%) and high lymphocyte (67.2722.50%) in peripheral blood. At the time of presentation, aplastic anaemia was moderate in 59.04% cases, severe in 48.19% cases and mild cases. We estimated the prevalence of aplastic anemia in 4 district of Karnataka including tea garden areas was 2.98/ million population per year.

IJBAR (2014) 05 (10) www.ssjournals.com 20,000/cmm, platelet count, 20,000/cmm). Rest of the cases were classified as mild AA when bone marrow hypocellularity and two or three cytopenias persisted for more than 6 weeks, but not so severe to fulfill the criteria for moderate AA 11,12 . Standard statistical methods were used for analysis of data.

Observations
100 cases of AA consisting of 83 males (83.13%) and 17 females (16.87%) were included in this study. The male to female ratio was 4.93:1 children (less than 15 years of age) accounted for 25 cases (25.30%) ( Table 1).   History of drug intake (chloramphenicol, Chloroquine iburprofen and other drugs known to cause marrow depression) was present in 11 cases (10.84%), exposure to insecticides, fungicides and fertilizers was found in 13 cases (13.25%) and history of hepatitis was noted in 8 cases (8.43%). However the role of fertilizers and insecticides could not be analysed with appropriate pharmacological and biological study for the detection of traces of chemical compounds due to the lack of such laboratory facility in this institution. The onset was insidious in 92 cases (91.57%). The significant clinical manifestations were weakness (found in all cases), pallor in 74 cases (74.70%) ,fever in 55 cases (55.42%), history of bleeding episodes form at least one site in 48 cases (48.19%) and localized infection (in skin, mucus membrane, throat, lungs and gut) in 25 cases 98.43%), (table 2). Hepatomegaly was observed in 8 cases (8.43%), and none of them had lymphadenopathy or spleenomegaly.
Peripheral blood showed anemia in all cases, leucopenia in 90 cases (90.36%), thrombocytopenia (in 94 cases, 93.98%) and neuropenia below corpuscles (RBC) were predominantly normocytic but mild anisocytosis was noted in 27 cases (27.71%). The mean differential neutrophil and lymphocyte counts in peripheral blood were 30.28 and 67.27 per mm 3 respectively ( Table 3). The average reticulocyte count was 0.3%. Stainable iron (indicating adequate iron store) was normal or increased in all cases. We did not estimated Hb-F or other abnormal haemoglobin as some of patients had already received blood transfusion on an emergency basis at presentation. Bone marrow examination revealed adequate sampling with decreased cellularity in all cases. Histological section of the aspirated marrow particles revealed better architectural relationship between the cellular and fat components. Bone marrow in aspirated smears (Leishaman x100) and trephine biopsy revealed increased reduction of cellularity (<30%) was noted in 37 cases (37.35%). An absence of cell trail in aspirated material was noted in 78 cases (78.31%). Presence of hot spots ie. Focal areas of hypercellular marrow (H&E x50) were observed in 23 cases (22.89%) and mild dyserythropoietic changes were noticed in 23 cases (22.89%).
Abnormalities in LFT (raised liver enzymes and /or hypoproteinaemia) were detected in 6 cases (6.02%), while normal renal function was noted in all cases. HBsAg was positive in 2 cases (2.41%) and anti-HCV was not detected in any case. Moderate AA was most prevalent at the time or presentation (n=59 cases, 59.04%), and that was followed by severe AA (n=37:37.35%). Mild AA at the time of presentation was least frequent and was noted in 4 cases (3.61%) ( Table 4).

Discussion
Children accounted for 25.30% of the total cases of AA in this study, while in the west this age group accounts for 16.4% of the total cases of AA 13 . However different studies showed that AA is more common in children in Asia, accounting for up to 30% cases 14 . A study at Mumbai (Bombay) India reported 29% cases occurred under the age of 10 year 6 . In this study, the male to female ratio was 4.93, which was higher compared to other studies conducted in the orient 3 (1.4 to 4.1) and India (1.31) 6 .
IJBAR (2014) 05 (10) www.ssjournals.com The increased ratio of fat to cellular areas as well as architectural pattern of fat spaces confirms the diagnosis of AA. How ever, bone marrow aspiration may be inconclusive due to presence of hypercellular foci, and bone marrow biopsy is helpful to exclude proliferative and infiltrative marrow disease and thereby establishes the diagnosis of AA. In the present study, the clinical features along with peripheral blood picture suggested and bone marrow examination confirmed the diagnosis of all cases. We observed that the marrow yield was satisfactory with plenty of hypocellular particle obtained in all cases, and focal hypercellularty in 23 cases (22.89%). According to Zhang et al 15 , the confirmation of AA requires correlation of different diagnosis techniques, and trephine biopsy alone can detect 93.6% of cases. We have used different techniques (bone marrow aspiration smears, histological section of aspirated particle and trephine biopsy) to increase the diagnostic accuracy. Normal or raised marrow iron found in this study might reflect decreased iron utilization by the marrow and occasional areas of active erythropoiesis.
The probable aetiology was identified in 33 cases (32.53%) in this series. Among them 13 (13.25%) had a history of exposure to insecticides and fertilizers, 11 (10.84%) had suggestive drug history of hepatitis before the onset of symptoms AA. However we could not definitely establish the aetiological factors as the role of fertilizer and insecticides could not be analysed by detecting traces of organ phosphorus and other compounds due to lack of sophisticated laboratory facility in this institution. An escalating use of insecticides and fertilizer, particularly in the tea plantation area, might be a contributing factor of AA. There are some reported cases of AA due to insecticides from the South East Asia14. we did not find any case of congenital AA which is in contrast to the 10.81% of cases as reported by Mehta et al 6 . However in that study the diagnosis of congenital AA was done solely on clinical basis. We have observed similar clinical features of children with AA with that of adult. However the occurrence of fever indicating local or systemic infection were found to be significantly higher (p=0.0365) when compared with the adult patients. Associate malnutrition might be a contributory factor in children for increased susceptibility of infection.
BRIMS Teaching Hospital, is the only referral center in 4 rural northern districts of west Bengal with a modern blood bank, and this area does not have private set-up with blood component separation unit. It can be assumed that patients of AA attending this institute approximately reflect the occurrence of AA in that area, was 9,929,208 according to that data of census 2001 of India 9 . So, the estimated prevalence of AA (total 74 cases from these districts in 2.5 years) was 2.98/million population per year. However a population-based study is required to ascertain the true incidence of AA in the area.
It was found that AA was major non-malignant haematological disorder of northern rural districts of West Bengal. The clinical manifestations and bone marrow morphology were almost identical in adults and children. We noted that concurrent examination of smears and histological sections of particles obtained after bone marrow aspiration played a very important role in the diagnosis of AA. We identified the use of insecticide and fertilizers as a possible aetiological factor in rural and tea plantation areas.

Conclusion
It was concluded that aplastic anaemia is a major non-malignant haematological disease in this part of India and, and an increasing use of chemicals in agricultural and tea garden areas might be the responsible factor. Larger population bases study is suggested.