Dear Nurija, I am sorry, but it is impossible to evaluate the case on the basis of an exported PDF file. In order to evaluate the histology we have to be able to enlarge the images, which is not possible in an PDF file. Please be so kind and re-submit the case. If you need any assistance, feel free to contact either me or Monika Hubler.

Dear Nurija,  
I have added you images in jpg. format an in a normal size.  

I am sorry, but I have gone over these images several times, and beyond noting that the marrow is hypercellular and seems to have some focal lesions, I cannot make out anything. I'm having trouble with it. The focal areas could be areas of necrosis, hemorrhage, inflammation; I just don't know. Were tests done for acute hepatitis or hepatic necrosis? I would start there.

Dear colleagues,  
I was downloading all pictures for this case and I hope that you will not have problems with interpretation of them.  
Thank you for patience.  
 
 

Thanks Monika for uploading the images, now we can enlarge them as usual. However I agree with Diane, I as well have looked at the images several times, the interpretation is very difficult. There are several focal lesions, which can be well appreciated in the stains for HB and MPO. They look like granulomas. My impression on the hemopoiesis is that myelopoiesis is left-shifted (maturation arrest?). Megakaryopoiesis seems to be hyperplastic, reactive to increased demand in the periphery? There seems to be normal maturation of erythropoiesis. There is a diffuse lymphoid infiltrate, consisting mainly of T-cells, which is most probably reactive. It does not look like a lymphoma infiltrate.  
My over all impression is that this is a reactive marrow, with granuloma-like areas, but I cannot point to any etiology. Did you inquire which medication the patient did receive? drug hypersensitivity might be an option.

I favour this being a reactive process.  
There is splenomegaly, marked hyper-bilirubinaemia and erythroid hyperplasia. The marked increase in bilirubin is either due to impaired hepatic function or haemolysis. There is marrow erythroid hyperplasia, in keeping with erythroid response to haemolysis. The foci in the marrow could be reactive (lymphoid) cells.  
 
Questions:  
1. Has a Direct Antiglobulin test been performed?  
2. Has a Lactate Dehydrogenase been performed?  
3. How much of the bilirubin is conjugated and unconjugated?  
4. What is the rest of the hepatic function?  
5. Can you show pictures of the blood film? Are there spherocytes or other red cell morphological abnormalities?

Dear colleagues,  
I received some information from our clinicians about this patient.  
Total bilirubin: 420 ng/l ; direct bilirubin :171 Indirect bilirubin: 249  
LDH: 757  
AST: 173  
ALT: 384  
Comb's test: negative  
Peripheral blood: pancytopenia with microcytic anaemia without spherocytes  
Staphilococcus aureus in blood .  
Thank you for your interesting comments and help.