- Email: [email protected]
Gaucher disease and β-thalassemia: A rare coinheritance
Accepted Manuscript Gaucher disease and β-thalassemia: A rare coinheritance
Alexandros Makis, Meropi Tzoufi, Eleni Pappa, Ioannis Kyrochristos, Anastasia G. Zikou, Vasileios Xydis, Maria I. Argyropoulou, Nikolaos Chaliasos PII: DOI: Reference:
S1079-9796(17)30117-1 doi: 10.1016/j.bcmd.2017.04.007 YBCMD 2185
To appear in:
Blood Cells, Molecules and Diseases
Received date: Revised date: Accepted date:
23 March 2017 19 April 2017 20 April 2017
Please cite this article as: Alexandros Makis, Meropi Tzoufi, Eleni Pappa, Ioannis Kyrochristos, Anastasia G. Zikou, Vasileios Xydis, Maria I. Argyropoulou, Nikolaos Chaliasos , Gaucher disease and β-thalassemia: A rare coinheritance. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ybcmd(2017), doi: 10.1016/j.bcmd.2017.04.007
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
TITLE OF THE LETTER Gaucher disease and β-thalassemia: a rare coinheritance
To the Editor Gaucher disease (GD) and thalassemia, both autosomal recessive disorders,
PT
may present with similar signs and symptoms such as anemia, splenomegaly and
RI
skeletal involvement [1, 2] and their coexistence may pose a diagnostic challenge.
SC
The scarce reports of simultaneous occurrence of GD and thalassemia, including ours, underline the necessity of high clinical suspicion and highlight the difficulties in
NU
differential diagnosis [3, 4].
A 6-year-old Greek boy presented with a 5-month history of vague abdominal
below
the
subcostal
margin
MA
pain. His father had β-thalassemia major. On admission, the spleen was palpable 4 cm and
the
laboratory
findings
showed
mild
D
thrombocytopenia (platelets 120 x 109/L) and microcytic anemia (Hb=110 g/L,
PT E
MCV=63 fL) with basophilic stippling. White blood cell count, inflammatory markers and biochemical results were within normal range (Table A). The chest X-ray was
CE
normal and the abdominal ultrasound confirmed the splenomegaly with spleen size of 12.7 cm (normal values <10.2).
AC
Our first priority was to rule out β-thalassemia due to history of the father and the combination of splenomegaly, microcytic anemia and basophilic stippling of the child. Hemoglobin electrophoresis and molecular testing were indicative of heterozygous β-thalassemia. The boy was heterozygous for the IVS I.116 βthalassemia mutation while his father had both the IVS I.116 and the codon 39 mutations (Table A).
ACCEPTED MANUSCRIPT 2
Given the fact that profound splenomegaly could not be attributed solely to heterozygous β-thalassemia, further laboratory examinations were performed. The clinical history, the blood and imaging findings and the serological testing ruled out infections,
chronic
autoimmune,
inflammatory
diseases
and
malignancies.
Furthermore, the clinical and laboratory picture was not compatible with congenital
PT
spleen diseases, splenic trauma, chronic heart failure, or portal hypertension. Finally,
RI
the possibility of lipid deposition disorders such as Gaucher and Niemann-Pick
SC
disease was investigated. Leukocyte β-glucosidase levels were low (0.9 nmoles/mg protein/hr, normal range 6-23) and plasma chitotriosidase was elevated (4419
NU
nmoles/ml/hr, normal range 0-150). These values were indicative for GD. Molecular testing was performed and the boy was found compound heterozygous for the
MA
mutations N370S/D409H:H225Q (Table A).
The absence of neurological findings, the low β-glucosidase and high
D
chitotriosidase levels, as well the presence of the N370S mutation, were all indicative
PT E
for the non-neuropathic type 1 GD [5]. A comprehensive further assessment of all potentially affected organ systems was performed. The MRI spleen volume was 7.8
CE
multiples of normal (MN) and the liver volume 1.9 MN (Figure A1) and were calculated using normal spleen volume = 2 mL/kg multiplied by body weight in kg
AC
and normal liver volume = 25 mL/kg multiplied by body weight in kg [6]. X-rays of the extremities showed osteopenia more pronounced in the femurs and a coarsened pattern due to trabecular resorption. Metaphyseal expansion creating the characteristic appearance of “Erlenmeyer flask” was also observed. X-rays of the spine showed a “bone within the bone” appearance of the vertebral bodies indicative of bone growth disturbance [6]. MRI of the spine and femurs was used to evaluate the bone marrow infiltration, according to the Bone Marrow Burden score classification system [7].
ACCEPTED MANUSCRIPT 3
The bone marrow of the spine was classified as grade III (definitely hypointense in comparison with the signal intensity of the intervertebral disk and presacral fat), and of the femur’s as grade II (hypointense in comparison with the signal intensity of the subcutaneous fat). Enzyme replacement treatment with imiglucerase was then initiated, since our
PT
patient had symptomatic disease at an early age along with the active bone
RI
manifestations and the increased spleen volume > 2 MN [8]. Imiglucerase was
SC
administered intravenously, every 2 weeks at a dose of 60 IU/kg. Six months later, the platelet and hemoglobin levels were within normal range and plasma chitotriosidase
NU
was significantly reduced. Twelve months after the initiation of treatment the values of hemoglobin, platelets and chitotriosidase were normal (Table A). Mild
MA
splenomegaly - 2 cm below the subcostal margin - was still present, possibly due to underlying heterozygous β-thalassemia. MRI of the abdomen showed significant
D
reduction of the splenic volume (7.8 MN versus 4.9 ΜΝ), and non-significant
PT E
reduction of the volume of the liver (1.9 MN versus 1.8 MN) (Figure A2). Signal intensity of the bone marrow was increased with grade II in lumbar spine grade I in
CE
the femur. All these findings were indicative of a good response on enzyme replacement therapy. Imiglucerase was well tolerated during this period, without any
AC
adverse effects.
There are only two reports describing this rare epiphenomenon of the coexistence of a lysosomal disease with a hemoglobinopathy. In the first report, MiriMoghaddam et al present five offsprings, who inherited both the GD G377S mutation and α-thalassemia 3.7 deletion from their combined heterozygous consanguineous parents [3]. All the children had microcytic anemia. The first three children had also splenomegaly and thrombocytopenia and were diagnosed as GD1 (homozygous for
ACCEPTED MANUSCRIPT 4
the G377S mutation). One of them was also homozygous for the alpha thalassemia 3.7 deletion and two heterozygous. The two younger children initially were falsely considered to have GD1, but finally were found heterozygous for the G377S mutation and homozygous for the alpha thalassemia 3.7 deletion. The second report by Chatterjee T et al, concerns a 2-year-old girl with microcytic anemia and massive
PT
splenomegaly. The investigation revealed both homozygous HbE thalassemia and GD
RI
and the severe anemia and splenomegaly were attributed to the co-existence of both
SC
diseases [4].
Although not reported, the presence of a hemoglobin disorder in a GD patient
NU
could potentially have an impact on the severity of clinical presentation, as well as on the treatment outcome, because both diseases cause anemia and splenomegaly.
MA
Additionally, the iron overload might contribute to the oxidative stress and inflammation caused by the macrophages. There are no reports of the outcome of GD
D
patients who also have heterozygous β-thalassemia, as our patient, but it is an
Concluding,
PT E
interesting field to investigate. in
patients
with
unexplained
microcytic
anemia,
CE
thrombocytopenia and splenomegaly, thalassemia has to be excluded, especially in countries with high percentage of thalassemia carriers. Even in these cases, the
AC
possibility of GD has to be early included in the differential diagnosis.
ACCEPTED MANUSCRIPT 5
AUTHORS Alexandros Makis1, Meropi Tzoufi1, Eleni Pappa2, Ioannis Kyrochristos3, Anastasia G. Zikou4, Vasileios Xydis4, Maria I. Argyropoulou4, Nikolaos Chaliasos1 1
Child Health Department, Faculty of Medicine, University of Ioannina, Ioannina,
Greece Department of Internal Medicine, Faculty of Medicine, University of Ioannina,
PT
2
Department of Surgery, Faculty of Medicine, University of Ioannina, Ioannina,
SC
3
RI
Ioannina, Greece
Greece
Department of Radiology, Faculty of Medicine, University of Ioannina, Ioannina,
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4
CORRESPONDING AUTHOR
MA
Greece
D
Alexandros Makis, Assistant Professor in Pediatrics/Pediatric Hematology, Child
45110
Ioannina,
PT E
Health Department, Faculty of Medicine, University of Ioannina, P.O. Box 1187, GRGreece,
Tel:
+30
2651099598,
Fax:
+30
2651007038,
CE
email: [email protected]
AC
FIGURE LEGEND
Figure A. Axial Τ2 weighted MRI scans 1. Before treatment (left): splenomegaly (7.8 multiples of normal, MN) and hepatomegaly (1.9 MN) are seen 2. One year after treatment (right): significant reduction of the splenic volume (4.9 ΜΝ) and non-significant reduction in the liver volume (1.8 MN)
ACCEPTED MANUSCRIPT 6
REFERENCES [1] G.A. Grabowski, A. Zimran, H. Ida, Gaucher disease types 1 and 3: Phenotypic characterization of large populations from the ICGG Gaucher Registry, Am J
PT
Hematol, 90 Suppl 1 (2015) S12-18.
RI
[2] R. Origa, beta-Thalassemia, Genet Med, (2016).
SC
[3] E. Miri-Moghaddam, A. Velayati, M. Naderi, N. Tayebi, E. Sidransky, Coinheritance of Gaucher disease and alpha-thalassemia resulting in confusion
NU
between two inherited hematologic diseases, Blood Cells Mol Dis, 46 (2011) 88-91. [4] T. Chatterjee, K. Dewan, P. Ganguli, S. Das, A. Sharma, A.K. Sahni, P. Nath, A
MA
Rare Case of Hemoglobin E Hemoglobinopathy with Gaucher's Disease, Indian J Hematol Blood Transfus, 29 (2013) 110-112.
D
[5] E. Dimitriou, M. Moraitou, C. Troungos, K. Schulpis, H. Michelakakis, Gaucher
(2010) 195-196.
PT E
disease: frequency of the N370S mutation in the Greek population, Clin Genet, 78
CE
[6] W.L. Simpson, G. Hermann, M. Balwani, Imaging of Gaucher disease, World J Radiol, 6 (2014) 657-668.
AC
[7] P.L. Robertson, M. Maas, J. Goldblatt, Semiquantitative assessment of skeletal response to enzyme replacement therapy for Gaucher's disease using the bone marrow burden score, AJR Am J Roentgenol, 188 (2007) 1521-1528. [8] A. Zimran, How I treat Gaucher disease, Blood, 118 (2011) 1463-1471.
ACCEPTED MANUSCRIPT 7
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CE
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D
MA
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SC
RI
PT
Table A. Laboratory and imaging findings and treatment on admission and during the course of the treatment Baseline 6 12 months months Treatment Imiglucerase (Cerezyme®, Genzyme), 60 IU/Kg iv every 15 days Leucocytes, x 109/L 5.8 6.1 7.2 Hemoglobin, g/L 110 120 121 9 Platelets, x 10 /L 120 206 186 MCV, fl 63 64 64 Erythrocytes x 1012/L 5.5 5.7 5.8 Ferritin, pmol/L 49 42 50 ESR, mm/hr 16 12 10 Blood urea nitrogen, 7.8 3.9 4.6 mmol/L Creatinine, µmol/L 44.2 35.3 35.9 Potassium, mmoI/L 4.8 4.3 3.6 Sodium, mmoI/L 137 135 135 AST, IU/l 37 46 34 ALT, IU/l 11 17 21 Bone lesions Osteopenia, Erlenmeyer No significant flask deformity, “bone difference in X-rays, within the bone”. slightly hypointense Delayed bone growth, bone marrow Hypointense bone marrow Splenic volume, MN 7.8 4.9 Hepatic volume, MN 1.9 1.8 Bone Marrow Burden Spine: grade III Spine: grade II score Femur: grade II Femur: grade I MCV: mean corpuscular volume; ESR: erythrocyte sedimentation rate; AST: aspartate aminotransferase; ALT: alanine aminotransferase; MN: multiples of normal
ACCEPTED MANUSCRIPT
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Figure 1a
ACCEPTED MANUSCRIPT
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SC
RI
PT
9
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Figure 1b
Alexandros Makis, Meropi Tzoufi, Eleni Pappa, Ioannis Kyrochristos, Anastasia G. Zikou, Vasileios Xydis, Maria I. Argyropoulou, Nikolaos Chaliasos PII: DOI: Reference:
S1079-9796(17)30117-1 doi: 10.1016/j.bcmd.2017.04.007 YBCMD 2185
To appear in:
Blood Cells, Molecules and Diseases
Received date: Revised date: Accepted date:
23 March 2017 19 April 2017 20 April 2017
Please cite this article as: Alexandros Makis, Meropi Tzoufi, Eleni Pappa, Ioannis Kyrochristos, Anastasia G. Zikou, Vasileios Xydis, Maria I. Argyropoulou, Nikolaos Chaliasos , Gaucher disease and β-thalassemia: A rare coinheritance. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ybcmd(2017), doi: 10.1016/j.bcmd.2017.04.007
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
TITLE OF THE LETTER Gaucher disease and β-thalassemia: a rare coinheritance
To the Editor Gaucher disease (GD) and thalassemia, both autosomal recessive disorders,
PT
may present with similar signs and symptoms such as anemia, splenomegaly and
RI
skeletal involvement [1, 2] and their coexistence may pose a diagnostic challenge.
SC
The scarce reports of simultaneous occurrence of GD and thalassemia, including ours, underline the necessity of high clinical suspicion and highlight the difficulties in
NU
differential diagnosis [3, 4].
A 6-year-old Greek boy presented with a 5-month history of vague abdominal
below
the
subcostal
margin
MA
pain. His father had β-thalassemia major. On admission, the spleen was palpable 4 cm and
the
laboratory
findings
showed
mild
D
thrombocytopenia (platelets 120 x 109/L) and microcytic anemia (Hb=110 g/L,
PT E
MCV=63 fL) with basophilic stippling. White blood cell count, inflammatory markers and biochemical results were within normal range (Table A). The chest X-ray was
CE
normal and the abdominal ultrasound confirmed the splenomegaly with spleen size of 12.7 cm (normal values <10.2).
AC
Our first priority was to rule out β-thalassemia due to history of the father and the combination of splenomegaly, microcytic anemia and basophilic stippling of the child. Hemoglobin electrophoresis and molecular testing were indicative of heterozygous β-thalassemia. The boy was heterozygous for the IVS I.116 βthalassemia mutation while his father had both the IVS I.116 and the codon 39 mutations (Table A).
ACCEPTED MANUSCRIPT 2
Given the fact that profound splenomegaly could not be attributed solely to heterozygous β-thalassemia, further laboratory examinations were performed. The clinical history, the blood and imaging findings and the serological testing ruled out infections,
chronic
autoimmune,
inflammatory
diseases
and
malignancies.
Furthermore, the clinical and laboratory picture was not compatible with congenital
PT
spleen diseases, splenic trauma, chronic heart failure, or portal hypertension. Finally,
RI
the possibility of lipid deposition disorders such as Gaucher and Niemann-Pick
SC
disease was investigated. Leukocyte β-glucosidase levels were low (0.9 nmoles/mg protein/hr, normal range 6-23) and plasma chitotriosidase was elevated (4419
NU
nmoles/ml/hr, normal range 0-150). These values were indicative for GD. Molecular testing was performed and the boy was found compound heterozygous for the
MA
mutations N370S/D409H:H225Q (Table A).
The absence of neurological findings, the low β-glucosidase and high
D
chitotriosidase levels, as well the presence of the N370S mutation, were all indicative
PT E
for the non-neuropathic type 1 GD [5]. A comprehensive further assessment of all potentially affected organ systems was performed. The MRI spleen volume was 7.8
CE
multiples of normal (MN) and the liver volume 1.9 MN (Figure A1) and were calculated using normal spleen volume = 2 mL/kg multiplied by body weight in kg
AC
and normal liver volume = 25 mL/kg multiplied by body weight in kg [6]. X-rays of the extremities showed osteopenia more pronounced in the femurs and a coarsened pattern due to trabecular resorption. Metaphyseal expansion creating the characteristic appearance of “Erlenmeyer flask” was also observed. X-rays of the spine showed a “bone within the bone” appearance of the vertebral bodies indicative of bone growth disturbance [6]. MRI of the spine and femurs was used to evaluate the bone marrow infiltration, according to the Bone Marrow Burden score classification system [7].
ACCEPTED MANUSCRIPT 3
The bone marrow of the spine was classified as grade III (definitely hypointense in comparison with the signal intensity of the intervertebral disk and presacral fat), and of the femur’s as grade II (hypointense in comparison with the signal intensity of the subcutaneous fat). Enzyme replacement treatment with imiglucerase was then initiated, since our
PT
patient had symptomatic disease at an early age along with the active bone
RI
manifestations and the increased spleen volume > 2 MN [8]. Imiglucerase was
SC
administered intravenously, every 2 weeks at a dose of 60 IU/kg. Six months later, the platelet and hemoglobin levels were within normal range and plasma chitotriosidase
NU
was significantly reduced. Twelve months after the initiation of treatment the values of hemoglobin, platelets and chitotriosidase were normal (Table A). Mild
MA
splenomegaly - 2 cm below the subcostal margin - was still present, possibly due to underlying heterozygous β-thalassemia. MRI of the abdomen showed significant
D
reduction of the splenic volume (7.8 MN versus 4.9 ΜΝ), and non-significant
PT E
reduction of the volume of the liver (1.9 MN versus 1.8 MN) (Figure A2). Signal intensity of the bone marrow was increased with grade II in lumbar spine grade I in
CE
the femur. All these findings were indicative of a good response on enzyme replacement therapy. Imiglucerase was well tolerated during this period, without any
AC
adverse effects.
There are only two reports describing this rare epiphenomenon of the coexistence of a lysosomal disease with a hemoglobinopathy. In the first report, MiriMoghaddam et al present five offsprings, who inherited both the GD G377S mutation and α-thalassemia 3.7 deletion from their combined heterozygous consanguineous parents [3]. All the children had microcytic anemia. The first three children had also splenomegaly and thrombocytopenia and were diagnosed as GD1 (homozygous for
ACCEPTED MANUSCRIPT 4
the G377S mutation). One of them was also homozygous for the alpha thalassemia 3.7 deletion and two heterozygous. The two younger children initially were falsely considered to have GD1, but finally were found heterozygous for the G377S mutation and homozygous for the alpha thalassemia 3.7 deletion. The second report by Chatterjee T et al, concerns a 2-year-old girl with microcytic anemia and massive
PT
splenomegaly. The investigation revealed both homozygous HbE thalassemia and GD
RI
and the severe anemia and splenomegaly were attributed to the co-existence of both
SC
diseases [4].
Although not reported, the presence of a hemoglobin disorder in a GD patient
NU
could potentially have an impact on the severity of clinical presentation, as well as on the treatment outcome, because both diseases cause anemia and splenomegaly.
MA
Additionally, the iron overload might contribute to the oxidative stress and inflammation caused by the macrophages. There are no reports of the outcome of GD
D
patients who also have heterozygous β-thalassemia, as our patient, but it is an
Concluding,
PT E
interesting field to investigate. in
patients
with
unexplained
microcytic
anemia,
CE
thrombocytopenia and splenomegaly, thalassemia has to be excluded, especially in countries with high percentage of thalassemia carriers. Even in these cases, the
AC
possibility of GD has to be early included in the differential diagnosis.
ACCEPTED MANUSCRIPT 5
AUTHORS Alexandros Makis1, Meropi Tzoufi1, Eleni Pappa2, Ioannis Kyrochristos3, Anastasia G. Zikou4, Vasileios Xydis4, Maria I. Argyropoulou4, Nikolaos Chaliasos1 1
Child Health Department, Faculty of Medicine, University of Ioannina, Ioannina,
Greece Department of Internal Medicine, Faculty of Medicine, University of Ioannina,
PT
2
Department of Surgery, Faculty of Medicine, University of Ioannina, Ioannina,
SC
3
RI
Ioannina, Greece
Greece
Department of Radiology, Faculty of Medicine, University of Ioannina, Ioannina,
NU
4
CORRESPONDING AUTHOR
MA
Greece
D
Alexandros Makis, Assistant Professor in Pediatrics/Pediatric Hematology, Child
45110
Ioannina,
PT E
Health Department, Faculty of Medicine, University of Ioannina, P.O. Box 1187, GRGreece,
Tel:
+30
2651099598,
Fax:
+30
2651007038,
CE
email: [email protected]
AC
FIGURE LEGEND
Figure A. Axial Τ2 weighted MRI scans 1. Before treatment (left): splenomegaly (7.8 multiples of normal, MN) and hepatomegaly (1.9 MN) are seen 2. One year after treatment (right): significant reduction of the splenic volume (4.9 ΜΝ) and non-significant reduction in the liver volume (1.8 MN)
ACCEPTED MANUSCRIPT 6
REFERENCES [1] G.A. Grabowski, A. Zimran, H. Ida, Gaucher disease types 1 and 3: Phenotypic characterization of large populations from the ICGG Gaucher Registry, Am J
PT
Hematol, 90 Suppl 1 (2015) S12-18.
RI
[2] R. Origa, beta-Thalassemia, Genet Med, (2016).
SC
[3] E. Miri-Moghaddam, A. Velayati, M. Naderi, N. Tayebi, E. Sidransky, Coinheritance of Gaucher disease and alpha-thalassemia resulting in confusion
NU
between two inherited hematologic diseases, Blood Cells Mol Dis, 46 (2011) 88-91. [4] T. Chatterjee, K. Dewan, P. Ganguli, S. Das, A. Sharma, A.K. Sahni, P. Nath, A
MA
Rare Case of Hemoglobin E Hemoglobinopathy with Gaucher's Disease, Indian J Hematol Blood Transfus, 29 (2013) 110-112.
D
[5] E. Dimitriou, M. Moraitou, C. Troungos, K. Schulpis, H. Michelakakis, Gaucher
(2010) 195-196.
PT E
disease: frequency of the N370S mutation in the Greek population, Clin Genet, 78
CE
[6] W.L. Simpson, G. Hermann, M. Balwani, Imaging of Gaucher disease, World J Radiol, 6 (2014) 657-668.
AC
[7] P.L. Robertson, M. Maas, J. Goldblatt, Semiquantitative assessment of skeletal response to enzyme replacement therapy for Gaucher's disease using the bone marrow burden score, AJR Am J Roentgenol, 188 (2007) 1521-1528. [8] A. Zimran, How I treat Gaucher disease, Blood, 118 (2011) 1463-1471.
ACCEPTED MANUSCRIPT 7
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D
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RI
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Table A. Laboratory and imaging findings and treatment on admission and during the course of the treatment Baseline 6 12 months months Treatment Imiglucerase (Cerezyme®, Genzyme), 60 IU/Kg iv every 15 days Leucocytes, x 109/L 5.8 6.1 7.2 Hemoglobin, g/L 110 120 121 9 Platelets, x 10 /L 120 206 186 MCV, fl 63 64 64 Erythrocytes x 1012/L 5.5 5.7 5.8 Ferritin, pmol/L 49 42 50 ESR, mm/hr 16 12 10 Blood urea nitrogen, 7.8 3.9 4.6 mmol/L Creatinine, µmol/L 44.2 35.3 35.9 Potassium, mmoI/L 4.8 4.3 3.6 Sodium, mmoI/L 137 135 135 AST, IU/l 37 46 34 ALT, IU/l 11 17 21 Bone lesions Osteopenia, Erlenmeyer No significant flask deformity, “bone difference in X-rays, within the bone”. slightly hypointense Delayed bone growth, bone marrow Hypointense bone marrow Splenic volume, MN 7.8 4.9 Hepatic volume, MN 1.9 1.8 Bone Marrow Burden Spine: grade III Spine: grade II score Femur: grade II Femur: grade I MCV: mean corpuscular volume; ESR: erythrocyte sedimentation rate; AST: aspartate aminotransferase; ALT: alanine aminotransferase; MN: multiples of normal
ACCEPTED MANUSCRIPT
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Figure 1a
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Figure 1b