One more new case from us: It is about bone marrow findings in a 46-year-old Bosnian female that presented with signs of anemia and thrombocytopenia for several years.  
Bone marrow biopsy has been performed and the findings are presented here.  
Microscopically, hypercellular bone marrow was seen. Proliferation of platelates in all phases of development was prominent (sporadically and in aggregates). These cells were positive for CD117 (c-Kit) and von-Willebrand factor (VIII factor). Dyserithropoesis with megoblastic cells as well as dysplastic myelo (mono- and binuclear) cells were also present (MPO and LCA positive). Bone marrow contained also a reactive population of plasma cells (CD38 positive).  
Clinical diagnosis: Pancytopenia  
Histopathological diagnosis: Myelodysplastic syndrome (MDS)?  
Therapy: Not so far (the open question is how to treat this patient in order to prevent a progression to acute leukemia)?  
Please, give your opinion!

diane.c.farhi 2007-11-07 17:55	[comment sent by email] In my opinion, the cellularity is normal to increased for this age. The   M:E ratio appears to be about 2 or 3 to 1, which is normal.   Megakaryocytes are increased and morphologically unremarkable. I don't   know what to make of the FVIII stain. As an aside, the bone appears   thin and sparse, suggesting osteopenia. I would favor peripheral   consumption as the etiology of this patient's cytopenias, rather than   failure of production. Do you have CBC results? A reticulocyte count?   Any evidence of splenomegaly? This info would help with the diagnosis.
tzankov 2007-11-07 18:59	There is not enough morphological evidence to call the case "MDS". The bone marrow cellularity is slightly increased, myelopoiesis is left shifted, but maturating, erythropoiesis is megalo/makroblastic (Vit B12? folic acid? levels? concurrent therapy? methotrexate? other myelotoxic substances? azathioprine? considering the plasmocytosis-evidence of autoimmunopathies?), the megakaryopoiesis is increased and left shifted (increased turnover?). I would not recommend to treat the patient in any way before the diagnosis is established, since I am not at all convinced that this is an MDS.
erber 2007-11-08 10:17	The bone marrow is mildly hypercellular for age with erythroid and megakaryocytic hyperplasia. The morphology does not appear to be dysplastic. Peripheral consumption or destruction of red cells and platelets could account for the cytopenias. This could be due to immune causes, and when combined Evans Syndrome. I suggest a direct antiglobulin test to diagnose an autoimmune haemolytic anaemia, and platelet antibody investigation (if available).
SergeyN 2007-11-08 10:43	Would consider B12/folate deficiency first. Red line is megaloblastic, neutrophyl hypersegmentation is difficult to appreciate at low magnification, but there are large metamyelocytes. Dysmegakaryopoesis is not too dramatic, in additional there are large forms, too.     It would be nice to know laboratory parameters of the anaemia in question (HGB, MCV, MCHC, reticulocytes, B12 level, iron/ferritin, bilirubin, etc.) Has she ever been treated with B12/folate?
semir 2007-11-08 15:47	In the meantime, we found out that the patient has been treated for megaloblastic anemia for several years. Increased number of reticulocytes in peripheral blood was noticed.   No signs of visceromegaly.   On the other side, she has been treated for her psychosis, too. Thus, antipsychotic drugs have been induced.
hurwitz 2007-11-08 19:58	I agree with the previous comments. I also think that the cytopenia is due to increased demand in the periphery,as expressed by the marked hyperplasia of morphologically unremarkable megakaryocytes. The appearaces are not of an MDS, but rather reactive. Therefore I do not think that you should worry about possible progression to AL. Thanks for the additional clinical data, they help in the interpretation of findings, which are possibly a combination of two factors, regeneration after treated megaloblastic anemia, and drug induced changes.   Compliments for your nice Giemsa stain, however I have difficulties in the interpretation of your immunostains, in particular CD45,MPO and v.Willebrand Factor. My impression is that there are many false positive cells, overstaining?
hurwitz 2007-11-08 23:39	Sorry I forgot an important detail.I would like to stress, as all my collegues the improtance of clinical and laboratory data for diagnosis of hematologic diseases. Bone marrow histology is only one factor, which has to be complemented by the rest.
anpo 2007-11-08 23:40	It extremely difficult to confirm or exclude MDS diagnosis without evaluation of bone marrow smears. Is it possible to take photos of a smear?
sirje 2007-11-09 08:01	I agree with dr.Porwit. The cellulariy of marrow seem to be around normal value(for the age). Dysplastic changes are mild, only left shifted erythropoiesis show megaloblastoid features. Cytopenia may be due to peripheral destruction of red cells and platelets by drug induced immunological reactions combined with deficiency status (B12? Folic acid?).
ffrenchma 2007-11-09 18:55	A woman, 46 years old presenting an anemia and thrombocytopenia since several years.   This anemia is regenerative since reticulicyte count is high (how much ?).   We need to know the erythrocyte volume, and the exact data of peripheral blood count.   Cellularity of bone marrow semms normal.   - we observe an increase in number of erythroblasts which present a macrocytosis.   - Megakaryocytes seem correct.   A diagnosis of MDS is not possible on these pictures.     I think necessary to obtain the result of bone marrow smear analysis, of iron staining. It will be useful to perform reticulin staining which can be increased in an auto-immune disease and indeed in MDS.   It will be very usefull also to know also result of coombs and others clinical data such as existence of pain, renal function inflammatory syndrom etc.
metz 2007-11-15 04:02	I don't think it is possible to diagnose MDS on bone marrow   trephine only, unless there is obvious megakaryocytic dysplasia. I too would favour increased peripheral consumption as a cause of the pancytopenia, but without examination of peripheral blood and bone marrow aspirate smears, and many of the tests recommended above by the others, I don't believe an accurate diagnosis is possible.
hurwitz 2007-12-14 17:13	There is a clearcut consensus on this case, the suggested final diagnosis:   Slightly hypercellular marrow with erythroid and megakaryocytic hyperplasia and megaloblastic erythropoiesis. No evidence of MDS or other primary hematologic disease.   Pancytopenia, probably due to increased demand in the periphery. Anemia probably multifactorial (Vit B12?, folic acid? drug induced changes?)
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