Granulomatous lesions in the bone marrow – An experience from a tertiary care centre

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International Journal of Medical Science and Current Research (IJMSCR) Available online at: www.ijmscr.com

Volume1, Issue 1,Page No: 62-65 May-June 2018

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Granulomatous lesions in the bone marrow – An experience from a tertiary care centre

Suhail Farooq* ,Nusrat Bashir * ,Dekyong Angmo**,Tazeen Jeelani*, Bilal Musharaf*,Ruby Reshi* *Department of Pathology, GMC,Srinagar, J&K India.

Email id: suhailfarooq@gmail.com, bashirnusrat@ymail.com,Tazeenjeelani@gmail.com , bilalmusharaf@gmail.com,rubyreshi@gmail.com

**Department of Microbiology , SKIMS,Srinagar, J&K India. Email id: angmodekyong1@gmail.com

Corresponding Author: Nusrat Bashir, Lecturer, Department of Pathology, government medical college, Srinagar,

Jammu and kashmir,India,190010

Type of Publication: Original Research Paper Conflicts of Interest: Nil

ABSTRACT

Bone marrow examination is an important tool in the diagnosis of non haematological disorders like granulomatous lesions, storage diseases and metastatic tumors. Of 470 bone marrow biopsies from Jan 2015 to Dec 2017, Granulomatous lesions were seen in 8 cases. Cause of granulomas were identified in 7 cases with 3 cases confirmed as that of tuberculosis on AFB culture , 1 case was that of enteric fever and 2 cases tested positive for brucella on serology.

Keywords: NIL

INTRODUCTION:

Examination of the bone marrow is central to the evaluation, diagnosis and management of many diseases including Hematologic as well as Non-Hematologic diseases. Even with the advancement in biochemical and molecular assays, the primary diagnosis of many neoplastic as well as

non-neoplastic Hematologic and Non-hematologic

disorders relies upon examination of the cells in the marrow. Aspiration and biopsy of marrow may confirm, rule out or provide a useful clue in the diagnosis of various disorders.

Granulomas in the bone marrow are an infrequent and nonspecific finding. However presence of granuloma may point to certain diseases. The diseases that are associated with granuloma formation in marrow biopsies include chronic

inflammatory conditions like mycobacterium

tuberculosis, fungi, sarcodiasis and mycoplasma.1,2,3 Granulomas may also be found in patients with Hodgkin’s and Non-Hodgkin lymphoma, with or without marrow involvement, and in occasional cases of a drug reaction.45

Materials and methods:

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granulomas. Serological tests conducted for HIV were noted .

Observations and Results:

The current study includes 8 cases depicting epithelioid cell granulomas on light microscopy in bone marrow examination. 5 were males and 3 females. Most of patients presented with nonspecific symptoms like fever, easy fatigability and loss of appetite. Complete blood count (CBC) depicted pancytopenia as the most common presenting feature, followed by anemia. 3 out of 6 cases had well defined epitheloid cell granulomas with langhan’s giant cells(Fig-1, fig-2) in trephine biopsy. Out of these 3 cases one case showed epithelioid cells in the bone marrow aspirate smear as well.. One case depicted caseating necrosis as well (Fig-4). This case also presented with cervical lymph node enlargement

which on FNAC showed granulomatous

lymphadenitis with acid fast bacilli positive on modified Zeil Nelson stain. . Acid fast bacilli were demonstrated in all the 3 cases (50%) on culture(Fig-5). Rest of the 3 cases had ill defined granulomas with histiocytes in biopsy.. Out of these 3 cases one case was that of enteric fever which presented with severe anemia . Two cases were confirmed as brucella positive on serology with one case showing histiocyte collection (Fig-3) only and other case showing ill defined granulomas . We could not find specific cause of granuloma in one out of our eight cases. Granulomas were seen mainly in the paratrabecular space.. One of the patient positive for TB on culture was found to be co-infected with HIV. There was no case of sarcoidosis , fungal infection or malignancy in our study.

Discussion:

Granuloma formation is an uncommon finding in the bone marrow examination with a reported incidence between 0.3% and 2.2%.6These granulomas consist of clusters of epithelioid histiocytes with accompanying lymphocytes, and giant cells.7 It is a nonspecific finding pointing towards a number of disease including viral, bacterial, fungal infections; malignant diseases; autoimmune diseases; drugs and sarcodiasis. Most of the cases in our study presented with nonspecific symptoms like fever, easy fatigability and loss of appetite. A no. of studies describe these symptoms as presenting feature in

bone marrow.8 Presence of granulomas in bone marrow narrows down the spectrum of diseases. After thorough clinical history and laboratory investigations, a specific etiology of epithelioid cell granulomas in bone marrow examination can be achieved in most of the cases. In our study we could found a specific cause for most of the cases (7 out of 8).9 Most of the cases could be attributed to infectious diseases particularly TB, which is consistent with most of the studies in literature which depict infectious diseases like tuberculosis as the most common cause of bone marrow granulomas.10,11 Our study shows a case of coinfection of TB and HIV presenting as granuloma in the bone marrow. HIV-TB Co infection cases with granulomatous lesions in bone marrow have been described.12 Our study describes a case of typhoid which presented with severe anemia showed presence of ill defined epitheloid cell granulomas on bone marrow

examination. Patients with typhoid depicting

granulomas in the bone marrow examination have been described.13 A case positive for brucella culture were seen depicted well defined epitheloid cell granulomas on bone marrow examination. Cases of brucella have been described in literature who present with granulomas on bone marrow examination.14

Conclusion:

Presence of granulomas in the bone marrow may be seen in a number of diseases. Despite various tuberculosis control programmes in our country tuberculosis still remains the most common cause of bone marrow granulomatous lesions.

Limitations:

Small Sample size

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