Armed Forces Institute of Pathology

OBJECTIVE:To characterise the clinical presentation, diagnostic spectrum, and management challenges of primary immunodeficiencies (PIDs) in Pakistan, with an emphasis on barriers to early diagnosis and optimal care in a resource-limited setting. STUDY DESIGN:A descriptive cross-sectional study. Place and Duration of the Study: Department of Immunology, Armed Forces Institute of Pathology / AFBMTC / CMH / NUMS, Rawalpindi, Pakistan, from September 2021 to September 2024. METHODOLOGY:Patients with PIDs were evaluated. Clinical characteristics, disease distribution, warning signs, consanguinity, family history, gender, and bone marrow transplantation were analysed. Age at diagnosis and diagnostic delay were reported as descriptive statistics. RESULTS:A total of 185 patients with PIDs were diagnosed, including 116 (63%) males and 69 (37%) females. Parental consanguinity was reported in 144 (78%) cases, while 62 (34%) had a positive family history of PIDs. The most common category was phagocytic defects identified in 63 (34%) patients, followed by humoral defects in 51 (28%), combined immunodeficiencies in 39 (21%), complement deficiencies in 26 (14%), and other PIDs in 6 (3%). The mean age at diagnosis was 7.4 ± 9.3 years (0.1-38 years), with a mean diagnostic delay of 3.5 ± 4.7 years. Bone marrow transplantation was performed in 21 (11%) patients, with an overall survival rate of 80%. CONCLUSION:PIDs are underdiagnosed in Pakistan due to limited awareness, lack of newborn screening, inadequate diagnostics, and high consanguinity. Improved clinician training, expanded diagnostic capacity, and a national PID registry are essential for earlier diagnosis and better outcomes. KEY WORDS:Bone marrow transplant, Consanguinity, Diagnostic delay, Inborn error of immunity, Jeffrey Model Foundation warning signs, Primary immunodeficiencies.

Background: Type 2 diabetes mellitus (T2DM) is a growing global health concern characterized by chronic hyperglycemia, insulin resistance and associated complications. Serum ferritin an iron storage protein and inflammatory marker has been linked to poor glycemic control and may provide insight into the interplay between iron metabolism, inflammation and diabetes management. Objective: To assess the correlation of glycemic control with serum ferritin levels. Methods: This comparative cross-sectional study was performed at the Department of Pathology and Endocrinology, Fauji Foundation Hospital, Rawalpindi from December 2023 to May 2024. Data of patients attending the diabetic clinic were included and distributed into two groups: Group A (patients with good glycemic control) and Group B (patients with poor glycemic control). Blood samples from patients included in this study were collected and analyzed for the levels of serum ferritin, CRP and HbA1C. Descriptive variables were presented as frequency, percentages and median accordingly. Results: In this study of 160 participants, divided based on glycemic control, group A had a lower median HbA1C of 5.70% compared to 8.10% in group B. Group B also had a higher median serum ferritin level (348.00 µg/L versus 161.5 µg/L). Additionally, group A had lower levels of C-reactive protein (0.3 mg/dL) compared to group B (0.4 mg/dL). Higher serum ferritin and CRP levels were strongly correlated to increased HbA1C levels. Conclusion: Increased ferritin and CRP levels are strongly related to poorly controlled T2DM. Monitoring ferritin levels in glycemic care can enhance patient outcomes by allowing for better risk assessment ...............

Objectives:To develop a low-cost, in-house conventional polymerase chain reaction method for leishmania tropica for epidemiological surveillance of disease. METHODS:The cross-sectional study was conducted at the Department of Microbiology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from October 16, 2023, to April 16, 2024, and comprised biopsy samples received for the diagnosis of cutaneous leishmaniasis. Deoxyribonucleic acid was extracted from the samples and was subjected to real-time polymerase chain reaction for the detection of the leishmania genus on a commercially available detection kit. Positive samples were then run by conventional in-house polymerase chain reaction with primers specific to leishmania tropica targetting covering internal transcribe spacer 2 and 18S ribosomal ribonucleic acid region. The in-house conventional polymerase chain reaction was validated by using extracted deoxyribonucleic acid from the promastigote of leishmania tropica as the positive control. The nucleotide sequence was subjected to the basic local alignment search tool, and a phylogenetic tree was constructed on MEGA 5.. RESULTS:Of the 73 suspected leishmaniasis cases, 64(87.7%) were from male subjects. Real-time polymerase chain reaction detected leishmania in 33(45.2%) of the samples, which were then assessed by the in-house polymerase chain reaction specific to leishmania tropica and 28(84.8%) samples were detected positive (p=0.0003). Sequencing of the internal transcribe spacer 5.8S region and subsequent phylogenetic analysis with 1000 bootstraps showed >95% identity with L.tropica. BLAST analysis showed 96-98% sequence identity (query coverage 98-100%, E-value = 0.0). CONCLUSIONS:The development of in-house polymerase chain reaction to test for leishmania tropica was successful in clinical samples, providing a cost-effective alternative to commercially available kits.

The diagnostic industry in recent times had demonstrated an exponential growth, aiming for more innovative and pioneering efforts to broaden the horizon of precision diagnostics. Witnessing a biotechnological cloudburst boom allowing us to leapfrog from prosaic diagnostics to unfolding the molecular mysteries in genome. The nascency of novel analytical methodologies have empowered to learn the human genetic code sequence. This amplification of DNA served as an “ice breaker” moment for the diagnostic industry to push further the scientific momentum to allow technology to translate preliminary “Sanger sequencing” to accomplish the “Human Genome Project” (HGP).1 The generational growth enhanced sequencing yield by next generational sequencing (NGS), allowing higher coverage, read length and depth, potentiated further by precise & accurate bioinformatics allowing manageable translation to clinics at desirable scale. Wholesome management systems like Maser (Management and Analysis System for Enormous Reads) has allowed to dig deep to terabytes with more clinical flexibility.2

OBJECTIVE:To detect WT1 gene alterations among individuals diagnosed with acute myeloid leukaemia (AML) and investigate their relation to the response of induction therapy. STUDY DESIGN:A descriptive study. Place and Duration of the Study: Department of Haematology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from June to December 2023. METHODOLOGY:The study enrolled all freshly diagnosed AML patients who underwent clinical, haematological, and molecular testing. Based on their WT1 mutation status, participants were categorised into distinct groups and assessed after four weeks of induction therapy. Independent t-test and chi-square tests were used to analyse the variables, while odds ratios (ORs) with 95% confidence intervals (CIs) were computed using cross-tabulation. RESULTS:Within the cohort of 98 newly diagnosed AML cases, patients had a mean age of 36.5 years, showing a male predominance with a male-to-female ratio of 1.22:1. WT1 mutations were detected in 12 (12.2%) patients. These patients showed significantly lower haemoglobin, higher leucocyte counts, reduced platelet counts, and higher bone marrow blast percentage (p <0.05). Complete remission occurred in 75% of WT1-mutated versus 62.8% of wild-type patients (p = 0.408). Although not statistically significant, WT1 mutations demonstrated a trend towards a more aggressive presentation and poorer therapeutic response. CONCLUSION:WT1 mutation in AML is associated with aggressive disease and less differentiated French-American-British (FAB) subtypes. Although remission rates were lower in WT1-mutated cases, the difference was not statistically significant. Larger prospective studies are needed to establish its prognostic significance and guide individualised therapy. KEY WORDS:Acute myeloid leukaemia, WT1 mutation, Induction therapy, Prognosis, FAB classification.