Mieloma múltiple en paciente joven / Multiple Myeloma in Young Patient

Introducción: el mieloma múltiple es una enfermedad hematológica maligna caracterizada por una proliferación de células plasmáticas en la médula ósea. La edad más común del inicio es entre 65 y 70 años, sin embargo se documentan casos en jóvenes en formas cada vez más graves. Presentación de caso: hombre de 31 años, que cursa con dolores óseos generalizados, pérdida de peso y adinamia, de 6 meses de evolución. Se constatan cifras de creatinina y calcio sérico elevadas durante su hospitalización, presenta proteína de Bence-Jones positiva para cadenas ligeras Kappa, y se realiza biopsia de médula que concluye en mieloma plasmoblástico. Conclusiones: se comienza tratamiento con citostático asociado a esteroides. La presentación antes de los 40 años es infrecuente y el pronóstico, sombrío, a pesar del tratamiento oncoespecífico(AU)

Introduction: Multiple myeloma is a malignant hematologic disease characterized by a proliferation of plasma cells in the bone marrow. The most common age of onset is between 65 and 70 years, however cases are documented in young people in increasingly severe forms. Case presentation: A case of a 31-year-old man, with generalized bone pain, weight loss and adynamia, of 6 months of evolution is presented here. Serum creatinine and serum calcium levels are high during hospitalization, Bence-Jones protein is positive for Kappa light chains, and marrow biopsy is performed, which concludes in plasmoblastic myeloma. Conclusions: Treatment with cytostatic associated with steroids is started. This onset before age 40 is not frequent, and prognosis is bleak, despite the specific oncology treatment(AU)

Place of Bone Marrow Biopsy as Compared to Bone Marrow Aspiration in Different Haematological Disorders.

Bone marrow aspiration (BMA) is much more frequently used than bone marrow biopsy (BMB) in the diagnosis of different haematological disorders. BMB is performed primarily in cases where bone marrow aspiration either fails or gives insufficient information. It is the sole modality of diagnosis in some situations and may give useful information of prognostic importance. The present study was done to find comparative usefulness of each of these procedures in various hematological disorders. Methods: Study subjects included all 45 patients attending the hematology section of pathology department of College of Medicine & Jawaharlal Nehru Memorial Hospital, Kalyani for bone marrow aspiration and who also consented for bone marrow biopsy during the period from 1st July 2011 to 30th June 2012. BMA smears and BMB specimens were obtained from posterior superior iliac spine in the same sitting and stained with Leishman’s stain and Haematoxylin & Eosin stain respectively. Findings of BMA and BMB were compared. Results: BMA was diagnostic in all cases of iron deficiency anemia (IDA), acute myeloid leukemia (AML), chronic myeloid leukemia (CML), chronic lymphocytic leukemia (CLL), idiopathic thrombocytopenic purpura (ITP) and essential thrombocythemia (ET). On the whole, BMA was diagnostic in 82.2% of cases and could accurately reveal hypercellularity in all cases. BMB was the only diagnostic method in myelofibrosis (MF) and provided additional information like fibrosis in cases of AML, CML and MF & pattern of involvement in CLL and multiple myeloma (MM). BMB, however, was poor in assessing iron stores due to leaching of iron during decalcification. Conclusions: BMA alone is sufficient for IDA and ITP. BMB is mandatory for diagnosis of MF and provides additional prognostic information in other cases.

Changing patterns of AIDS: impact on the indications and diagnostic yield of bone marrow biopsies

After the advent of HAART, the clinical course of HIV infection has dramatically improved. Therefore, it seems appropriate to reevaluate the performance of bone marrow biopsy (BMB) as a diagnostic tool. The aim of the present study was to compare the reasons for performing a BMB and its diagnostic yield in HIV-patients before and after HAART. A total of 165 BMB specimens obtained from HIV-infected patients receiving care at the Hospital of Universidade Federal do Rio de Janeiro in two different periods (1986-1994 and 1999-2004) were analysed. The main reason for BMB examination in the first period was fever (88 percent), which decreased in the second period (57 percent, p < 0.0001), when cytopenia (51 percent) was the leading reason for BMB, whereas in the first period it accounted for only 30 percent (p = 0.008). A definitive diagnosis (infection, granulomas or lymphomas) was obtained in 28 percent of patients in the first period and in 19 percent during the second period (p = 0.20). The diagnosis turned out as infections decreased from 16 percent in period 1 to 2 percent in period 2 (p = 0.003). Despite the the limitations in the evaluation of fever, the use of BMB must be considered on an individual basis, whenever less invasive alternatives have been exhausted, and should be complemented by a bone marrow aspiration for microbiological studies.

É necessária a realização de biópsia de medula óssea bilateral para o estadiamento do linfoma difuso de grandes células B? / Is it necessary to perform a bilateral bone marrow biopsy to stage diffuse large B-cell lymphoma?

Estudo retrospectivo que visa analisar a utilidade da biópsia de medula óssea (BMO) bilateral na infiltração de medula óssea (MO) por linfoma difuso de grandes células B (LDGCB). Nossos objetivos foram avaliar a incidência de infiltração unilateral de MO por LDGCB e comparar o comprimento dos fragmentos obtidos entre as amostras positivas e negativas para infiltração. Além disso, verificamos se houve diferença entre os casos com infiltração unilateral versus bilateral, correlacionando com desidrogenase láctica (DHL) e estadiamento tomográfico. Avaliamos 268 casos de LDGCB e observamos infiltração medular em 34 casos (13 por cento). Não foi possível a avaliação de seis casos, restando 28 casos para análise. Foram revisados no total 70 fragmentos de MO sobre presença ou ausência de infiltração e comprimento. A média do número de fragmentos por casos foi 2,5; a média do comprimento dos fragmentos foi 11,01 mm (± 5,12 mm), e a média do comprimento dos fragmentos por caso foi 27,53 mm. Foi observado que em seis casos (21,4 por cento) havia infiltração unilateral. Não foram evidenciadas diferenças nas médias do comprimento dos fragmentos em relação à presença versus ausência de infiltração 10,95 mm (± 5,1 mm) versus 11,57 mm (± 5,2 mm), p > 0,05, respectivamente. Não foram evidenciadas diferenças em 23 casos entre a comparação da infiltração medular unilateral versus bilateral com DHL e estadiamento tomográfico. Concluímos que a BMO bilateral foi superior à unilateral, pois pode aumentar a detecção de infiltração de MO em 21,4 por cento dos casos.

This retrospective study aims to analyze the usefulness of bilateral bone marrow biopsy in bone marrow infiltration by diffuse large B-cell lymphoma (DLBCL). Our objectives were to assess the incidence of unilateral BM involvement by DLBCL and compare fragment length obtained from positive and negative samples for infiltration. Furthermore, we compared the differences between unilateral and bilateral infiltration correlating with lactic dehydrogenase (LDH) and computerized tomography (CT) staging. We evaluated 268 cases of DLBCL and observed medullary infiltration in 34 cases (13 percent). It was not possible to evaluate 6 out of 34 cases. 70 BM fragments were reviewed as to the presence or absence of infiltration and length. The mean number of fragments per case was 2.5; the mean BM fragment length was 11.01 mm (± 5.12 mm) and the mean BM fragment length per case was 27.53 mm. There was unilateral BM infiltration in six cases (21.4 percent). There were no differences in the mean fragment length as to the presence/absence of infiltration 10.95 mm (± 5.2 mm) versus 11.57 mm, p > 0.05, respectively. There were no differences in 23 cases between the comparison of unilateral medullary infiltration versus bilateral with lactic dehydrogenase and CT staging. We concluded that bilateral bone marrow biopsy was superior to unilateral because it may increase by 21.4 percent the detection of BM involvement by DLBCL.

Clinically unsuspected Hodgkin's lymphoma diagnosed primarily from bone marrow trephine biopsy: report of six cases.

Bone marrow may be the initial or rarely the only site of involvement in Hodgkin's lymphoma. A high index of suspicion is required to pick up the histopathological changes of Hodgkin's lesions in the bone marrow like necrosis, presence of Reed-Sternberg cell or its variant in a polymorphic background infiltrate, focal fibrosis and myxoid change especially in the absence of classical clinical picture. Bone marrow with immunohistochemistry has a valuable role in the staging and in the diagnosis of primary medullary Hodgkin's lymphoma. B-symptoms may easily masquerade as an infectious process as in all our cases the patients had fever as a presenting feature, in four of them tuberculosis was suspected clinically and two had received antitubercular therapy elsewhere. We report six human immunodeficiency virus-negative patients diagnosed over a period of 5 years in which the initial diagnosis of Hodgkin's lymphoma was suggested from bone marrow histology.

Compreendendo a experiência de crianças e adolescentes submetidos à punção de medula óssea e lombar em centro cirúrgico de um hospital oncológico / Understanding the experience of children and adolescents to undergo bone marrow aspiration and lumbar surgery center in a hospital cancer

Atualmente, o câncer infantil é bastante compreendido e estudado, apresentando altas probabilidades de cura, graças aos avanços da ciência e da tecnologia. Porém, quando este diagnóstico é dado a crianças ou adolescentes ele ainda gera desconfortos, devido ao impacto que esta doença pode causar no desenvolvimento destes indivíduos. Tanto a fase de diagnóstico, quanto as etapas do tratamento incluem a realização de procedimentos invasivos, bem como a utilização de drogas agressivas. O objetivo deste estudo foi compreender a experiência de crianças e adolescentes submetidos a procedimentos de punção de medula óssea e punção lombar realizadas em uma Unidade de Centro Cirúrgico de um Hospital Oncológico, sedadas antes da realização dos mesmos. Foi realizado um estudo qualitativo, utilizando-se o Discurso do Sujeito Coletivo (DSC) para a organização dos dados, e para análise dos resultados foi elaborado um Quadro Teórico. Foram entrevistados 15 sujeitos nos períodos pré e pós-procedimentos, na faixa etária de 7 a 14 anos de idade, procedentes de diversos Estados do Brasil. A maioria deles é do sexo masculino, com diagnóstico de Leucemia Linfoblástica Aguda (LLA). De acordo comos resultados foram construídos 18 DSC que revelaram, além de aspectos positivos quanto à importância da sedação antes da execução dos procedimentos, noções sobre o tratamento e a doença, assim como, satisfação pelo atendimento recebido, sentimentos como medo, ansiedade, devido ao tempo de espera na etapa do pré-procedimento e insegurança quanto à cura. Foram reveladas também dificuldades quanto à realização do tratamento, como a dependência de transporte público, da rotina hospitalar, a separação da família, a distância da escola e dos amigos. Oferecer uma assistência tecnicamente diferenciada ainda é insuficiente para minimizar as adversidades enfrentadas por estes indivíduos e suas famílias...

Pattern of hematological diseases in hospitalized pediatric patients based on bone marrow examination

The objective of this study was to look into various diagnoses of hematological lesions on bone marrow examination in our pediatric age group of patients. This study was conducted in the Pediatric A Unit and Department of Hematology Postgraduate Medical Institute [PGMI] Lady Reading Hospital, Peshawar from 01st Jan 2007 to 31st Dec 2007. Children admitted with pallor, bleeding, lymphadenopathy or visceromegaly having abnormal smear results were included in this study. The data was statistically analyzed by SPSS version 10. One hundred and ninety-eight cases were included in the study. The age range was from 06 months to 14 years with a mean age of 5.35 years and standard deviation of +/- 3.69. Majority [4 7.5%] of these children were in the age range of 1 to 5 years with male to female ratio of 1.53. The commonest disorder was aplastic anemia present in 40 [20.2%] of the cases followed by idiopathic thrombocytopenic purpura [ITP] [15.7%], megaloblastic anemia [14.6%] and iron deficiency anemia [7.6%]. Acute leukemia was the predominant malignant disorder present in 11.6% of the cases. There were also few cases of histiocytosis and bone marrow secondaries. Visceral leishmaniasis, anemia of chronic disorders, haemolytic anemia, myeloid hyperplasia, hypersplenism, congenital dyserythropoietic anemia, malaria and Gaucher disease were the other non-malignant hematological disorders found in this study. Aplastic anemia, idiopathic thrombocytopenic purpura, megaloblastic anemia and leukemia are the commonest hematological disorders in our set up

Role of bone marrow trephine biopsy in the diagnosis of marrow involvement in Hodgkin's disease.

Bone marrow involvement in Hodgkin's disease alters the stage and hence the prognosis and treatment modality. Seventy-six patients of biopsy proven Hodgkin's disease in whom a bone marrow aspiration and biopsy were done simultaneously at the time of diagnosis were included in the study. Bone marrow involvement was seen in 14 (18%) cases. All 14 cases were diagnosed on biopsy. Only one aspirate was suspicious of involvement. Rest was either diluted (28%) or was normal (64%). Eleven patients were upstaged from stage I, II and III to stage IV. All patients had cytopenia of one or more cell line. Increased fibrosis, necrosis and a polymorphic cellular infiltrate were associated findings in the marrow. We wish to highlight the importance of bone marrow trephine biopsy over aspirate in staging even clinically early stage Hodgkin's disease.

Erythrovirus B19 infection in acquired immunodeficiency syndrome: screening by histopathology, immunohistochemistry, and in situ hybridization

Erythrovirus B19 infects erythrocytic progenitors, transiently interrupting erythropoiesis. In AIDS patients it causes chronic anemia amenable to treatment. We looked for evidences of B19 infection in stored bone marrow material from patients with acquired immunodeficiency syndrome. Histological sections were made from stored paraffin blocks from 33 autopsies (39 blocks) and 35 biopsies (45 blocks, 30 patients) performed from 1988 to 2002. They were examined after hematoxylin-eosin (HE) staining, immunohistochemical (IHC), and in situ hybridization. HE revealed intra-nuclear inclusion bodies ("lantern cells") suggesting B19 infection in 19 sections corresponding to 19 of 63 patients examined with this test. Seven of 78 sections subjected to immunohistochemistry were positive, corresponding to 7 of 58 patients examined with this test. Fourteen sections corresponding to 13 of the 20 HE and/or IHC positive patients were subjected to in situ hybridization, with six positives results. Among the 13 patients subjected to the three techniques, only one gave unequivocal positive results in all and was considered a true positive. The frequency of B19 infection (1/63 patients) in the material examined can be deemed low.

The diagnostic utility of bone marrow trephine biopsies.

The bone marrow examination is invaluable in the diagnosis of certain haematological and non haematological conditions. The diagnosis of haematological disorders is achieved mainly by the examination of peripheral blood and bone marrow aspirate smears. Although bone marrow histology can provide additional information, for many technical reasons, trephines are not so popular and their diagnostic value is overlooked. Our experiences in the role of trephine biopsies in the diagnosis are presented in this article. All the bone marrow biopsies performed at the St. John's Medical College Hospital over the last 12 years (1990-2002) were reviewed The bone marrow biopsies were grouped into 3 categories for analysis. The trephine biopsy is invaluable in cases where the aspirate fails or is a dry tap as in the case of myelofibrosis, focal marrow involvement as in granulomatous lesions, metastatic tumour and lymphomas.

Segmentación de biopsias de médula ósea mediante filtros morfológicos y rotulación de regiones homogéneas / Segmentation of bone marrow biopsies by morphological filters and labeling of flat zones

Este trabajo presenta un método semi-automático de detección de tejidos em biopsias de médula óssea utilizando técnicas de Processamento Digital de Imagens. Las técnicas utilizadas combinan filtrados morfológicos y detección de regiones homogéneas, con el fin de realizar un cálculo preciso de la celularidad medular. Os informes anátomo-patológicos de estos cortes histológicos entregan resultados porcentuales de la celularidas medular, indicando la prsencia de trabéculas, células adiposas y hamatopoyéticas. Dichos porcentajes permiten evalular la presencia y/o el grado de algún desorden metabólico, estableciendo comparaciones entre los valores normales y los patológicos. Generalmente, estas mediciones se realizam por simples inspección visual. El método propuesto permite calcular el porcentaje de trabéculas, células adiposas y hematopoyéticas. La identificación de trabéculas se basa en la aplicación de Filtros Morfológicos Alternativos Secuenciales por Reconstrucción y rotulación de regiones homogéneas. Todo el proceso es implementado en lenguaje MatLab® 6.5 con una interfase visual que permite operar el sistema sin ser experto en Procesamiento de Imágenes. El método fue probado con 26 imágines de biopsias de médula óssea que presentam distribuciones variadas de trabéculas. Se presenta un análisis comparativo entre los resultados obtenidos con el método propuesto y los calculados por dos patólogos especialistas donde la diferencia entre ambas estimaciones es menor al 12 por cento, mientras que las diferencias entre ellos llegan a ser has de 20 por cento. Tanto los resultados visuales como los numéricos indican que el método es altamente eficiente para esta aplicación.

Granulomas in bone marrow--a study of fourteen cases.

Granulomas in bone marrow are an infrequent finding and several diseases are associated with granuloma formation. Clinicopathological details of fourteen cases showing granulomas in bone marrow were studied. Fever was the commonest clinical presentation and anaemia was seen in all cases. Only one case showed epithelioid cells in the bone marrow aspirate smear while trephine biopsy was diagnostic in all cases. Granulomas were seen mainly in the paratrabecular space. Acid fast bacilli were demonstrated in five biopsies and serological test for Human Immunodeficiency virus was positive in five cases. Tuberculosis was more common in the present study as compared to others, probably due to the endemicity of tuberculosis in this region. Bone marrow biopsy is useful in the investigation of pyrexia of unknown origin as it leads to an aetiological diagnosis in most cases.

Pancytopenia--a clinico haematological study of 200 cases.

The present study was designed to ascertain the percentage of occurrence and causes of pancytopenia. All the cases of pancytopenia from July 2001 to June 2002 (one year) were examined in the Department of haematology, Safdarjung Hospital, New Delhi. Bone marrow aspirations/biopsy were performed in most of the cases (200 out of 250 cases). The commonest cause of pancytopenia, in our hospital was Megaloblastic anaemia (72%), followed by Aplastic anaemia (14%) and others.

Concomitância de leishmanioses e infecçäo pelo vírus da imunodeficiência humana (HIV): estudo de quatro casos / Concurrent leishmaniasis and human immunodeficiency virus infection: a study of four cases

Säo apresentados quatro casos de leishmaniose em pacientes com SIDA, sendo dois de leishmaniose visceral e dois com forma cutâneo-mucosa. Lesöes cutâneas e de mucosa oral, disseminadas, estavam presentes nos pacientes com a forma tegumentar da doença. Febre prolongada, hepatoesplenomegalia e pancitopenia foram as manifestaçöes principais da forma visceral. A contagem de linfócitos TCD4+ era baixa em todos os casos. A pesquisa de leishmanias foi positiva no aspirado de medula óssea e na biópsia de lesöes cutâneas e mucosas. Os pacientes responderam ao tratamento com antimoniais pentavalentes e com a anfotericina B. Poucos casos de coinfecçäo leishmaniose e HIV têm sido descritos em nosso meio. Apesar da ampla expansäo de ambas, até agora suas áreas de distribuiçäo geográfica teve pouca superposiçäo. Os autores recomendam a inclusäo desta parasitose no diagnóstico diferencial das doenças oportunistas que acometem indivíduos com SIDA

Pancytopenia--a clinico-hematologic analysis of 77 cases.

The present study was conducted in the department of Haematology and Transfusion Medicine, Government Medical College & Hospital, Chandigarh over a period of 32 months. During this period pancytopenia was an indication for bone marrow (aspiration and or trephine) in 77 out of a total of 205 cases (37.6%). The most common cause of pancytopenia as revealed by bone marrow was megaloblastic anaemia (68%) followed by aplastic anaemia (7.70%). This study also revealed few uncommon and rare, but interesting causes of pancytopenia like drug induced agranulocytosis, hemophagocytic syndrome and waldenstroms macroglobinemia.

Histologic and histochemical studies on the bone marrow, spleen and liver in experimentally-induced chronic renal failure in the rat

Albino rat has been used as an animal model for adenine induced chronic renal failure. Animals were fed a diet containing 0.75% adenine in a dose of 250-350 mg/kg body weight/day for one month. Histologic and histochemical changes of bone marrow, spleen and liver were investigated. Bone marrow smear showed a hypocellularity in the from of a marked decrease of different stages of development of RBCs, leucocytes and megakaryocytes. This was associated with a marked increase in acid phosphatase enzyme activity and a decrease in succinic dehydrogenase enzyme activity. Numerous mast cells were also observed. With the spleen, lymphocytic depletion was observed in the periarteriolar lymphatic sheath, the rest of lymphatic follicle and the red pulp. Macrophage number was apparantely increased in the red pulp. Haemosiderin granules showed a marked increase in the red pulp. Like with the bone marrow, an increase in activity of acid phosphatase enzyme and a decrease in succinic dehydrogenase enzyme activity were noticed in the red pulp. In the liver, hepatocyte vacuolation and increased number of von Kupffer cells were noticed. An increase in acid phosphatase enzyme activity and a decrease in succinic dehydrogenase enzyme activity were observed. There was a patchy depletion of glycogen granules

Bone marrow and histochemical features of malignant histiocytosis

To study the hematological and histochemical features of malignant histiocytosis cases diagnosed at King Khalid University Hospital. This is a retrospective analysis of malignant histiocytosis cases diagnosed by bone marrow examinations at the Hematology Section, Department of Pathology, King Khalid University Hospital. The medical records were evaluated for clinical symptoms and signs at presentation and peripheral blood count. Bone marrow aspirates and biopsies were reviewed for morphological features. Immunohisto-chemical staining of bone marrow trephine biopsies was performed. Over 11 years, from February 1984 to March 1995, four cases of malignant histiocytosis were diagnosed at King Khalid University Hospital [KKUH] in Riyadh. They were two males and two females. The age range was 25-56 years. The predominant symptoms at presentation were fever and fatigability. All patients had hepatomegaly and three had splenomegaly. One patient had localized lymphadenopathy and skin involvement. Three patients had pancytopenia while one patient had anemia, thrombocytopenia and leukocytosis. Immunohistochemical stains on three cases showed positivity with 1 antitrypsin and lysozyme. One case showed CDS [T cell marker] positivity by flow cytometry. The clinical, hematological and immunohistochemical staining findings are described