Hematological Features in Pancytopenia - a Study of 60 Pediatric Patients at Tertiary Care Hospital

Original Research Article

Hematological features in pancytopenia - A study of 60 pediatric patients at tertiary care hospital

Sapariya Brijeshkumar1, Godhani Suchi2*, Jagirdar Ami3, Patel Shilpa4, Thakrar Ila5

1Associate Professor, 2Tutor, 3Assistant Professor, 4Tutor, 5Tutor, Department of Pathology, SMIMER (Surat Municipal Institute of Medical Education and Research), Surat Municipal Corporation, Surat–395010, INDIA. Email: [email protected]

Abstract Background: The aim of the study is to co-relate hematological parameters with clinical findings in differentiating the etiologies of pancytopenia. Material and Method: This eighteen month long prospective study was carried out from August 2016 to October 2017 at department of Pathology of tertiary care hospital. Inclusion criteria were used to select cases after taking written and informed consent. Results: Out of total 60 patients, non-malignant conditions and malignant conditions were found in 95% and 5% respectively, in present study. In present study 53.34% (32 cases) cases were that of nutritional anemia, out of which 31.67% (19) were that of megaloblastic anemia, 16.67% (10 cases) were that of iron deficiency anemia and 5.0% (one case) were that of mixed nutritional anemia. Malaria was seen in 26.67% of cases of pancytopenia (16 cases), out of which 13 cases were that of Plasmodium vivax (81.25%), two cases were that of P Falciparum (12.5%) and one case was that of mixed infection (6.25%) cases. In the present study aplastic anaemia, dengue fever, typhoid fever, tuberculosis and acute leukemia were two cases each with pancytopenia (3.33%). Parvovirus B19 infection and myelodysplastic syndrome presented in one each case (1.67%). Hemoglobin percentage was ranged 2.5 – 9.8 gm %. 2.5 gm% of hemoglobin was seen in Iron deficiency anemia. 35% of cases have shown macrocytosis and 30% had normocytic normochromic picture in peripheral smear examination. Total leucocyte count ranged from 1000 to 4000 cells/mm3 and. A case of megaloblastic anemia had shown TLC of 1000 cells / mm3. Platelet count ranged from 7,000 to 1,40,000 /mm3. A case of megaloblastic anemia had shown platelet counts of 7,000 to 1,40,000 /mm3. Bone marrow aspiration has been performed in 20 patients (33.3%). Bone marrow was hyper cellular in nine cases (45%), normocellular in six cases (30%) and hypocellular in five cases (25%). Out of hypercellular bone marrow cases megaloblastic anemia was seen in 55.56% of cases, acute leukemia in 22.22% cases and nutritional anemia and iron deficiency anemia 11.11% each. Out of hypocellular bone marrow cases aplastic anemia and iron deficiency anemia were found in 33.33% each and parvo virus infection and dengue in 11.11% each.

*Address for Correspondence: Dr Godhani Suchi, Tutor, Department of Pathology, SMIMER (Surat Municipal Institute of Medical Education and Research), Surat Municipal Corporation, Surat–395010, INDIA. Email: [email protected] Received Date: 30/04/2021 Revised Date: 14/05/2021 Accepted Date: 08/06/2021 DOI: https://doi.org/10.26611/1051924 This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Access this article online INTRODUCTION Quick Response Code: Pancytopenia is a common pediatric hematological Website: finding characterized by reduction in all three major www.medpulse.in formed elements of blood – erythrocytes, leucocytes and platelets1. The underlying pathogenic mechanisms of

cytopenias are variable.2-4 Careful assessments of the

Accessed Date: blood elements is often the first step in assessment of 5 08 August 2021 hematologic function and diagnosis of disease. Physical findings and peripheral blood picture provide valuable

information in the work up of pancytopenia patients and

How to cite this article: Sapariya Brijeshkumar, Godhani Suchi, Jagirdar Ami, Patel Shilpa, Thakrar Ila. Hematological features in pancytopenia - A study of 60 pediatric patients at tertiary care hospital. MedPulse International Journal of Pathology. August 2021; 19(2): 46-54. https://www.medpulse.in/Pathology/ MedPulse International Journal of Pathology, Print ISSN: 2550-7605, Online ISSN: 2636-4697, Volume 19, Issue 2, August 2021 pp 46-54 help in planning investigation on bone marrow samples.6 Method of collection of data: Bone marrow evaluation is an invaluable diagnostic Source of data: Tertiary care hospital, pediatric ward procedure in practice of medicine which may confirm the patients. diagnosis of suspected cytopenias, from the clinical Sample size: Pancytopenia eighty patients features and peripheral blood examination or Selection of data: occasionally give a previously unsuspected diagnosis.7 Inclusion criteria: Aplastic anemia is the most common cause of the 1. Patients of group from 6 months to 18 years. pancytopenia as per a worldwide research study, which 2. Hb less than 10 gm %, leucocytes count less is contrast with studies done in India. Causes of the than 4000/ cu mm, platelet count less than 1.5 pancytopenia in pediatric age groups are not well lac/cu mm. defined, in India. However megaloblastic anemia is most Exclusion criteria: common cause of pancytopenia, as per previous Indian 1. Patients age less than 6 months and more than studies. Timely recognition of the underlying pathology 18 years. will not only have an impact on the mortality and 2. Hb more than 10 gm %,Leucocytes more than morbidity of the vulnerable pediatric patients but will 4000/cumm,Platelet more than 1.5 lac/cumm. also help to treat the most simple and easily treatable Collection of data: condition like megaloblastic anemia whose picture of Detailed clinical history and thorough examination of all presentation very drastic but can be managed. identified cases of pancytopenia were taken. Two ml of Aim and Objectives: anticoagulated blood was collected and evaluated in To study role of hematological parameters in automated hematology counter (Sysmex KX 21). differentiating the etiologies of pancytopenia. Peripheral smear examination, with giemsa stain,

malarial parasite detection, reticulocyte count was MATERIAL AND METHOD carried out. Other specialized hematological tests This 15 months long prospective observational study was coagulation profile, anti-human globulin test, sickling carried out from August 2016 to October 2017 at and G6PD (Glucose 6 phosphatase deficiency), Hb department of Pathology at tertiary care hospital. The electrophoresis carried out as and when needed. cases were selected on basis of inclusion criteria after Biochemical testes like vitamin B12, folate, irons studies, taking written and informed consent. Before starting of LDH, LFT were also performed. In some cases blood study, permission from institutional ethical committee culture, serological tests for HIV, hepatitis, dengue, was obtained. Ham’s test were carried out. 20 patients had undergone bone marrow examination as well.

OBSERVATIONS AND RESULTS 60 patients who presented with pancytopenia were studied. Following results were recorded and analyzed. Table 1: Distribution of various causes of pancytopenia in present study Causes No. of cases Percentage (%) 1 Non – malignant 57 95.00 Nutritional anemia 32 53.34 Megaloblastic anemia 19 31.67 Iron deficiency anemia 10 16.67 Mixed nutritional anemia 03 05.00 Infections 23 38.33 Malaria 16 26.67 Typhoid 02 03.33 Dengue 02 03.33 Pulmonary tuberculosis 02 03.33 Parvovirus B19 01 01.67 Aplas tic anemia 02 03.33 2 Malignant 03 05.00 Acute leukemia 02 03.33 Myelodysplastic syndrome 01 01.67 Total 60 100.00

Copyright © 2021, Medpulse Publishing Corporation, MedPulse International Journal of Pathology, Volume 19, Issue 2 August 2021 Sapariya Brijeshkumar, Godhani Suchi, Jagirdar Ami, Patel Shilpa, Thakrar Ila

Etiologically non-malignant conditions were commoner than malignant condition. In non-malignant conditions, nutritional anemia was more common in 53.34% cases followed by infections in 38.33% cases. In nutritional anemia, megaloblastic anemia was more common constituting the 31.67% of the cases. In infections, malaria was more encountered in 26.67 % cases. Malignancy was seen only in 5 % cases. Megaloblastic anemia was most common cause of pancytopenia followed by malaria was found in present study.

Chart 1: Etiologies of cases of pancytopenia in present study

Table 2: Values of hemoglobin in cases of pancytopenia in present study Serial No. Hemoglobin (gm %) range No. of cases Percentage (%) 1. upto 4 10 16.67 2. 4.1-7 27 45.00 3. 7.1-10 23 38.33 Total 60 100.00

Hemoglobin percentage: Hemoglobin percentage varied from 2.5 gm% – 9.8gm %. Most of patients had hemoglobin percentage between 4.1-7 gm%. Iron deficiency anaemia cases had shown Hb upto 2.5 gm%.

Chart 2: Values of hemoglobin in cases pancytopenia in present study

Table 3: Values of total leucocyte count in cases of pancytopenia in present study Serial No. Total leukocyte count(cells/mm3) range No of cases Percentage (%) 1. ≤1000 01 01.67 2. 1001-2500 11 18.33 3. 2501-4000 48 80.00 Total 60 100.00

Total leucocyte count: Total leucocyte count ranged from 1000 – 4000 cells/mm3. Megaloblastic anemia case has shown TLC count up to 1000 cells/mm3.

Chart 3: Values of Total Leucocyte Count in cases of pancytopenia in present study

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Table 4: Values of platelet count in cases of pancytopenia in present study Serial No. Platelet count (Lac/ mm3) range Cases Percentage 1. 0 – 0.5 31 51.67 2. 0.5 – 1.00 25 41.67 3. 1.00 – 1.5 04 06.66 Total 60 100.00 Platelet count: Platelet count ranged from 7000 – 1,40,000/mm3. Megaloblastic anemia had shown platelet count of 7000 /mm3.

Chart 4: Values of platelet count in cases of pancytopenia in present study

Table 5: Peripheral blood picture in pancytopenic patients Serial no. Blood picture No. of cases Percentage (%) 1. Normocytic Normochromic 18 30.00 2. Microcytic Hypochromic 16 26.67 3. Macrocytic 21 35.00 4. Dimorphic 05 08.33 Total 60 100.00

Peripheral blood picture: 35% of cases has shown macrocytosis (35%) followed by normocytic normochromic picture (30%).

Chart 5: Peripheral blood picture in cases of pancytopenia in present study

Table 6: Cellularity of bone marrow in present study Serial no. Type of cellularity No of patients Percentage (%) 1. Hyper cellular 09 45.00 2. Hypo cellular 06 30.00 3. Normo cellular 05 25.00 Total 20 100.00 Bone marrow aspiration has been performed in 20 patients. Hypercellular, hypocellular and normocellular bone marrow was observed in nine, six and five patients respectively.

Chart 6: Cellularity of Bone marrow in cases of pancytopenia in present study

Table 7: Causes of hyper cellular marrow associated with pancytopenia Serial no. Etiology No. of cases Percentage (%) 1. Megaloblastic anaemia 05 55.56 2. Acute leukemia 02 22.22 3. Mixed nutritional anaemia 01 11.11 4. Iron Deficiency anaemia 01 11.11 09 100.00 In hypercellular bone marrow, megaloblastic anemia was seen in 55.56 %, acute leukemia in 22.22%, mixed nutritional anemia and iron deficiency anemia in 11.11% cases each.

Table 8: Causes of hypo cellular marrow associated with pancytopenia Serial no. Etiology No. of cases Percentage (%) 1. Aplastic anaemia 02 33.33 2. Iron deficiency anaemia 02 33.33 3. Parvovirus infection 01 16.67 4. Dengue 01 16.67 06 100.00 In hypocellular marrow aplastic anemia and iron deficiency anemia in 33.33% cases and parvo virus and dengue in 11.11% cases of each.

Table 9 Incidence of malarial infection species types with pancytopenia in present study Serial Type of Malarial No. Percen No. species Infection of tage case (%) s 1. Plasmodium vivax 13 81.25 2. Plasmodium 02 12.50 falciparum 3. Mixed infection 01 06.25 16 100.00 Out of 16 malaria cases, 13 cases were that of plasmodium vivax (81.25%), two cases of plasmodium falciparum (12.5%) and one case of mixed infection (6.25%).

Chart 7: Incidence of type of malarial Species infection with pancytopenia in present study

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DISCUSSION The study entitled “Clinico – hematological study of pancytopenia in pediatric age group at tertiary care hospital.” was conducted in the Department of Pathology at our institute during the August 2016 to October 2017 on the 60 cases of pancytopenia. Statistical data of etiology, peripheral smear examination, biochemical analysis and bone marrow aspiration (as and when required) were studied, and compared with those published in the literature.

Table 10: various causes of pancytopenia compared to other studies of pediatric population Authors Year Place Number common causes of cases Syed nadeem et 2017 Pakistan 200 Megaloblastic anaemia (32%), aplastic anaemia (22%) al.11 and acute leukemia (18%) Waris et al.15 2017 Pakistan 69 Aplastic anaemia (42%), acute leukemia (22%) and megaloblastic anaemia (10%) Singh G et al.12 2016 India 153 Severe acute malnutrition (27.3%), leukemia (18.2%), dengue and thalassemia with hypersplenism (9.1%) in each, aplastic anaemia (1.1%) Dubey SRK et al.10 2016 India 170 Megaloblastic anaemia (47%), aplastic anaemia (25.8%), Kanpur leukemia (17.6%) Rathod GB et al.13 2015 India 200 Megaloblastic anaemia (26.5%), aplastic anaemia (Gujarat ) (20.0%), leukemia (17.5%) Anwar Zeb Jan et 2013 Pakistan 205 Aplastic anemia(28.3%), Leukemia (23.9%) and al.14 megaloblastic anemia(19.5%) Amieleena et al.9 2012 India(Uttark 91 Megaloblastic anaemia (31.8%), malignancies (25.2%), hand) infectious disease (19.7%) and aplastic anaemia (18.8%) Naseem et al.16 2011 India 571 Aplastic anaemia (33.8%), (Chandigarh) Acute leukemia (26.6%), Megaloblastic anaemia (13.7%) Sazia Memon et 2008 Pakistan 230 Aplastic anaemia (23.9%), Megaloblastic anaemia, al.8 leukemia (13% each), Malaria (8.69%) Gupta et al.17 2008 India 105 Aplastic anaemia (43%), Acute Leukemia (26.6%) Bhatnagar et al.18 2005 India 109 Megaloblastic anaemia (28%), Aplastic anaemia and infections(21% each) Present study 2017 India 60 Megaloblastic anaemia (31.67%), Malaria (26.67%) and IDA (16.67%), Aplastic anaemia and Malignancies (3.33% each) The variations in the frequency of various diagnostic entities causing pancytopenia has been attributed to difference in methodology and stringency of diagnostic criteria, geographic area, period of observation, genetic differences, prevalence of infection and varying exposure to myelotoxic agents, etc. The commonest cause of pancytopenia, reported from various studies throughout the world has been aplastic anaemia. This is sharp contrast with the results of our study where the commonest cause of pancytopenia was Megaloblastic anaemia (31.67%). All the above studies from which done in India, stress the importance of Megaloblastic anaemia being the major cause of pancytopenia. It is a rapidly correctable disorder and should be promptly notified.

Table 11: Comparisons of incidence of megaloblastic anemia to other studies Authors Yea No. of the Incidence of megaloblastic r cases Anemia Syed nadeem et al.11 201 200 32% 7 Waris et al.15 201 69 10% 7 Dubey SRK et al.10 201 170 47% 6

Rathod GB et al.13 201 200 26.5% 5 Amieleena et al.9 201 91 31.8% 2 Naseem et al.16 201 571 13.7% 1 Sazia Memon et al.8 200 230 13% 8 Bhatnagar et al.18 200 109 28% 8 Present study 201 60 31.67% 7 In present study, megaloblastic anemia was most common cause of pancytopenia in 31.67% of the cases, which was comparable to other studies like Dubey SRK et al.10 (47%), Rathod GB et al.13 (26.5%), Amieleena et al.9 (31.8%), and Bhatnagar et al.18 (28%).

Table 12: Comparison of incidence of other nutritional anemia to other studies Study Yea No. of the Incidence of Incidence of mix r cases IDA nutritional anemia Sayed nadeem et al.11 201 200 5% 3% 7 Rathod GB et al.13 201 200 9.5% - 5 Anwar Zeb Jan et al.14 201 205 4.4% - 3 Shazia Memon et al.8 200 230 - 8.69% 8 Present study 201 60 16.67% 5% 7 In present study iron deficiency anemia was seen in 16.67% of the cases, as compared to other studies all showed lower incidence of IDA. Incidence of mixed nutritional deficiency anemia in 5% cases, which comparable to Shazia Memon et al.8.

Table 13: Comparisons of various infectious etiologies to other studies Authors No. Incidenc Common infectious etiology of e cases of infection Waris et al. (2017)15 69 33% Enteric fever (17%), Malaria (6%), and visceral Leishmaniasis (7%) Rathod GB et al. 200 5% Malaria (3.5%), visceral leishmaniasis (1.5%) (2015)13 Singh G et al. (2016)12 187 24.7% Dengue (9.1%) Brucella and Malaria(5.9%) in each Amieleena et al. (2012)9 91 19.7% Kala azar (6.6%), Malaria (4.4%), and enteric Fever (2.2%) Shazia Memon et al. 230 28.2% Enteric fever (10.8%), (2008)8 Malaria and septicemia (8.7%) in each Present study (2017) 60 38.33% Malaria (26.67%), typhoid, dengue and tuberculosis (3.33%) in each, parvovirus B19 (1.67%)

In present study, infections were seen in 38.33% of cases which comparable to Waris et al.15, Shazia Memon et al.8 and Singh G et al.12. In infections, malaria was most common cause of pancytopenia in 26.67% of cases. In all other studies there was lower incidence of malaria, Waris et al.15 (6%), Rathod GB et al.13( 3.5%),Singh G et al.12 (5.9%),Amieleena et al.9 ( 4.4%), Shazia Memon et al.8 (8.7%). In present study, high prevalence of malarial infection causes the pancytopenia was due to high endemicity for malarial infection. Waris etal15 and Shazia Memon et al.8 found enteric fever was common

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among the infections, Singh G et al.12 found that dengue fever was 3rd most common cause of pancytopenia, and Amieleena et al.9 found kala azar was common among the infections. Difference in incidence of infectious etiology causes the pancytopenia depend on socioeconomic status and endemicityand prevalence of infection In present study, among the malarial infections P. vivax was seen in 81.25% of the cases, which accordance with Amieleena et al.9 and Rathod GB et al.13. Amieleena et al.9 found 4 cases of malaria, all were caused by p. vivax and Rathod GB et al.13 found 7 cases of malaria, from which 4 were caused by P. vivax and 3 were caused by P. falciparum. This was in accordance with Shazia Memon et al.8 and Singh G et al.12. Shazia Memon et al.8 showed that out of 20 cases of malaria, 15 cases caused by P. falciparum and Singh G et al.12 showed that out of 11 cases, 6 cases caused by P. falciparum.

Table 14: Comparisons of incidence of aplastic anemia to other studies Authors Yea No of the cases Incidence of r aplastic anemia Waris et al.15 201 69 22.00% 7 Singh G et al.12 201 187 1.10% 6 Rathod GB et al.13 201 200 20.00% 5 Naseem et al.16 201 571 33.80% 1 Gupta et al.17 200 105 43.00% 8 Present study 201 60 3.33% 7 In present study incidence of aplastic anaemia was 3.33% which correlated with the studies done by Singh G et al.12 in which aplastic anemia was seen in 1.1% cases. A higher incidence of 43% was reported by Gupta et al.17.

Table 15: Comparison of incidence of acute leukemia to other studies Study Yea No. of the cases Incidence of r acute leukemia Syed nadeem et al.11 201 200 18% 7 Singh G et al.12 201 187 18.2% 6 Rathod GB et al.13 201 200 17.5% 5 Naseem et al.16 201 571 26.6% 1 Sazia Memon et al.8 200 230 13% 8 Gupta et al.17 200 105 26.6% 8 Present study 201 60 3.33% 7 In present study, 2 cases of leukemia (3.33%) were seen, while in all other studies there was high incidence of leukemia. In present study, 1 case of Myelodysplastic syndrome was seen which comparable to the study Singh G et al.15 who had reported an incidence of 2.7%, and Rathod GB et al.13 reported 1.5% of cases.

CONCLUSION parvo virus infection is even very rare condition. In In present study nonmalignant conditions nutritional malignant conditions acute leukemia was commoner than anemia more common followed by infectious conditions. of myelodysplastic syndrome. Iron deficiency anemia Megaloblastic anemia and iron deficiency anemia are patients were had less hemoglobin as compared to other common in nutritional anemia, while mixed nutritional cases. Megaloblastic anemia cases were had more intense anemia is rare. Malaria is common infectious conditions, leukopenia, thrombocytopenia and hypercelluar bone while typhoid, dengue and tuberculosis were rare and marrow. In peripheral smear red cell morphology macrocytic picture was more common followed by

normocytic normochromic and microcytic hypochromic, 9. Amieleena Chhabra, Vipan Chandar, Anubhava patel, while bone marrow picture had much common harish Chandra, clinico- etiological profile of hypercelluar bone marrow; this could be because of pancytopenia in paediatric practice. JIACM 2012;13(4):282-285 megaloblastic anemia. As nonmalignant conditions are 10. Shiv Ram Krishna dubey, Suarabhkumarpatel, A.K. Arya, much more common, early detection and timely R.P. Singh. Clinico-etiological spectrum of pancytopenia management would be much beneficial in most of cases. in hospitilized children.:Int J Contemp Pediatr.2016 Feb;3(1):169- 172 REFERENCES 11. Syed Nadeem Mansoori, Muahmmad Ali, Fatima Muzee, Syed Maaz Nadeem, Wajeeha Nadeem, SyeedMoiz 1. Wintrobe‘s clinical haematology, 12th edition, Nadeem.Spectrum of Pancytopenia in Children Based Philadelphia; Lea and Febiger.1449-1476. upon Bone Marrow Study.P J M H S Vol.11, NO. 2, APR 2. Bates I, Bain BJ. Approach to diagnosis and classification – JUN 2017 661-663. of blood diseases.Dacie and Lewis Practical Hematology. 12. Singh G, Agrawal DK, Agrawal R. Etiological profile of 12th ed. Philadelphia: Churchill Livingstone; 2017.p.497- childhood pancytopenia with special reference to non- 508 malignant presentation. Int J Med Res Prof. 2016; 2(2): 3. Raja S, Suman FR, Scott JX, Latha MS, Rajenderan A, 204-08. Ethican A. Pancytopenia – (?) An obstacle in the diagnosis 13. Rathod GB, Alwani M, Patel H, Jain A. Clinico- and outcome of pediatric acute lymphoblastic hematological analysis of Pancytopenia in Pediatric leukemia.South Asian J Cancer. 2015; 4(2):68–71. patients of tertiary care hospital. IAIM, 2015; 2(11): 15- 4. Naseem S, Verma N, and Das R, Ahluwalia J. Pediatric 19. patients with Bicytopenia/Pancytopenia: Review of 14. Anwar Zeb Jan, Zahid B, Ahmad S, Gul Z .Pancytopenia etiologies and clinic hematological profile at a tertiary in children. Pak J Med Sci 2013; 29(5):1153-57. center. Indian J patholMicrobiol 2011; 54(1):75-80. 15. Waris R, Shahid G, Khalid ST, Riaz A, Rehman A. 5. Kumar R, Kalra SP, Kumar H, Anand AC, Madan H. Aetiology of Cytopenias in Children Admitted to a Pancytopenia: a six year study, JAPI 2001; 49: 1078–81. Tertiary Care Hospital JIMDC. 2017; 6(2):104-109. 6. Tilak V, Jain R. Pancytopenia: a clinico-hematologic 16. Naseem S, Verma N, Das R, Ahluwalia J. Pediatric analysis of 77cases. Indian J Pathol Microbiol1999; 42: patients with Bicytopenia/Pancytopenia: Review of 399–404. etiologies and clinic hematological profile at a tertiary 7. Nanda A, Base S, Marwaha N. Bone marrow trephine center. Indian J patholMicrobiol 2011; 54(1):75-80. biopsy as an adjunct to bone marrow aspiration. JAPI, 17. Gupta V, Tripathi S, Tilak V, Bhatia BD. A study of 2002; 50: 893-895. clinico-haematological profiles of pancytopenia in 8. Shazia Memon, Salma Shaikh and M. Akbar A. Nizamani. children. Trop Doct. 2008; 38(4):241-3. Etiological Spectrum of Pancytopenia Based on Bone 18. Bhatnagar SK, Chandra J, Narayan S, Sharma S, Singh V, Marrow Examination in Children. Journal of the College Dutta AK. Pancytopenia in children:etiological profile. J of Physicians and Surgeons Pakistan 2008, Vol. 18 (3): Trop Pediatr. 2005; 51(4):236-9. 163-167.

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