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Noiperm P, Saelue P. Predictive model for diagnostic yield of bone marrow examination in patients with HIV infection having fever of unknown origin. AIDS 2024; 38:185-192. [PMID: 37792352 PMCID: PMC10734777 DOI: 10.1097/qad.0000000000003744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/13/2023] [Accepted: 09/28/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE Bone marrow examination is valuable for identifying the cause of fever of unknown origin (FUO) in HIV-infected patients. Based on the outcomes of bone marrow examination of patients with FUO, we aimed to develop a predictive model for identifying the factors that can increase the diagnostic yield of bone marrow examination. DESIGN For this retrospective cohort study, we enrolled HIV-infected patients, aged more than 15 years and diagnosed with FUO, at Songklanakarind Hospital in Southern Thailand, between January 2009 and December 2019. METHODS Evaluations were based on bone marrow aspiration, biopsy, and culture; any missing data were imputed with regression imputation. RESULTS Among the final 108 included patients, 44 (40.74%) showed positive bone marrow results. The diagnoses mainly comprised histoplasmosis, penicilliosis, and tuberculosis. Bone marrow examination led to treatment modifications in approximately 33% patients. Platelet count less than 150 000 cells/μl, alkaline phosphatase (ALP) level at least 200 U/l, and no previous antibiotic treatment were significantly associated with higher diagnostic yields. The HIV bone marrow (HIVBM) model, comprising of spleen size, hematocrit (Hct), platelet count before bone marrow examination, ALP level at admission, and previous antibiotic treatment, was generated as a nomogram to predict the diagnostic yield of bone marrow examination in HIV-infected patients with FUO. CONCLUSION The results of this study indicate that the HIVBM model can be used to predict the diagnostic yield of bone marrow examination, and therefore assist in clinical decision-making regarding bone marrow procedures, to be performed for identifying the origin of fever in HIV-infected patients.
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Affiliation(s)
- Panarat Noiperm
- Hematology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
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Nomura Y, Mizukami A, Ueno K, Watanabe R, Kinoshita S, Fujiwara N, Kakuta K, Morita T, Asano K, Saito A. Epidural intracranial abscesses and multiple bone metastases caused by disseminated Mycobacterium avium complex infection: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22407. [PMID: 36471577 PMCID: PMC9724007 DOI: 10.3171/case22407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/24/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND Mycobacterium avium complex (MAC) generally causes localized pulmonary infections in immunocompromised hosts, but rarely in other organs and tissues, which is called disseminated MAC infection. OBSERVATIONS The authors herein present a 48-year-old male patient with disseminated MAC infectious lesions in the lungs and on the cranial, vertebral, femoral, and pelvic bones, a normal CD4 count, and immunopositivity for the interferon-ɤ (IFN-ɤ) neutralization antibody. Cranial lesions were multiple osteolytic lesions associated with abscesses in the cranial bones. The patient initially received conservative treatment with multiple antibiotics; however, cranial lesions worsened. Therefore, multiple cranial lesions were removed via osteoplastic craniectomy and the postoperative course was uneventful. Pathological findings revealed MAC infection. The patient was discharged without recurrence or complications. LESSONS Multiple cranial MAC dissemination with immunopositivity for the IFN-ɤ antibody is rare. The authors herein present the clinical course of a rare surgical case of MAC dissemination with a literature review.
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Sharvit G, Schwartz D, Heering G, Shulman A, Avigdor A, Rahav G, Toren A, Nagler A, Canaani J. Evaluation of the clinical impact of bone marrow cultures in current medical practice. Sci Rep 2022; 12:9664. [PMID: 35690634 PMCID: PMC9188585 DOI: 10.1038/s41598-022-14059-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 05/31/2022] [Indexed: 11/15/2022] Open
Abstract
The clinical yield and benefit of performing bone marrow cultures for various clinical indications has been challenged and their clinical necessity remains debatable. We sought to assess the clinical yield and benefit of performing routine bone marrow cultures and determine whether various clinical, laboratory, and imaging parameters were predictive of a diagnostic bone marrow culture. This was a single center retrospective analysis of all patients who underwent a bone marrow study comprising bone marrow cultures from January 1, 2012, through March 1, 2018. Baseline clinical data were extracted from the institution's electronic medical records system. The analyzed cohort consisted of 139 patients with a median age of 46 years (range 4 months to 85 years). The most common indication for a bone marrow study was workup of a fever of unknown origin (105 patients, 76%) while investigation for infection in immunocompromised patients accounted for 22 cases (16%) and suspected tuberculosis was the reason for acquisition of bone marrow cultures in 6 patients (4%). Only 3 patients had positive bone marrow cultures, yielding in 2 patients a diagnosis of Mycobacterium avium and in one patient a microbiologically unclassifiable fungal infection. A univariate analysis revealed that mean age, hemoglobin level, platelet count, c-reactive protein levels, gender, indication for bone marrow study, yield of blood cultures, and contribution of imaging studies and bone marrow pathology results were not significantly different between patients with diagnostic and non-diagnostic bone marrow cultures. Mean white blood cell count was found to be significantly lower in patients with diagnostic bone marrow cultures (2.4 × 103/µL versus 8.7 × 103/µL; P = 0.038). We conclude that for most patients, performance of bone marrow cultures holds limited clinical value.
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Affiliation(s)
- Gal Sharvit
- Division of Hematology, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Daniel Schwartz
- MetroHealth Medical Center, Case Western Reserve University, 2500 Metrohealth Dr, Cleveland, OH, 44109, USA
| | - Gabriel Heering
- Westchester Medical Center, 100 Woods Rd, Valhalla, NY, 10595, USA
| | - Alexander Shulman
- The Infectious Diseases Unit, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Abraham Avigdor
- Division of Hematology, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Galia Rahav
- The Infectious Diseases Unit, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Amos Toren
- Pediatric Hemato-Oncology Division, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Arnon Nagler
- Division of Hematology, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel
| | - Jonathan Canaani
- Division of Hematology, Chaim Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Hashomer, Derech Sheba 2, 52621, Ramat Gan, Israel.
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4
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Maiti S, Maiti KB. Gastrointestinal Tuberculosis and HIV Association in Tropics. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02844-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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5
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Hajiabdolbaghi M, Ataeinia B, Ghadimi F, SeyedAlinaghi S, Badie BM, Dadras O, Rasoolinejad M. Bone Marrow Aspiration/Biopsy in the Evaluation of Fever of Unknown Origin in Patients with AIDS. Infect Disord Drug Targets 2021; 21:394-398. [PMID: 32628601 DOI: 10.2174/1871526520666200705212903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/21/2020] [Accepted: 05/04/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND HIV can interrupt the normal development of bone marrow cell lines. Bone marrow aspiration/biopsy (BMA/B) has been described as a diagnostic tool in AIDS patients with fever of unknown origin (FUO). In this review, we aimed to study patients with AIDS who had undergone a BMA/B to investigate FUO and describe the pathologies diagnosed in the biopsy. METHODS Thirty-four BMA/B samples were collected from AIDS patients admitted for work-up of FUO to the infectious disease ward of a tertiary referral HIV center in Tehran, Iran, between September 2014 and September 2015. Data including age, sex, duration of disease, CD4 cell counts, hepatitis B (HBV) and C (HCV) coinfection, the primary presentation of AIDS, and the treatment history were retrieved and analyzed. Patients underwent BMA/B. An expert pathologist reviewed the BMA/B specimens. RESULTS The mean age of the patients was 37.5 years (range, 26-56), and 27 (79%) were men. Twenty-seven (79%) patients contracted HIV from injection drug use, and 7 (21%) via sexual transmission. Only 3 (9%) of the BMA/B examinations were normal. Hypocellular bone marrow was diagnosed in 22 (65%) patients. Other pathologies included granulomas in 6 (18%), hematologic malignancies in 2 (6%), and leishmaniasis Aspergillosis, each in 1 (3%) patient. Six (17%) of the specimens were found to have tuberculosis infections. CONCLUSION Hypocellular bone marrow was the most common pathology on BMA/B examinations, followed by the presence of granulomas. Tuberculosis, Aspergillosis, and Leishmaniasis the opportunistic infections diagnosed on BMA/B specimens. Our results support BMA/B as an appropriate diagnostic tool for early diagnosis of opportunistic infections and malignancies in AIDS. BMA/B is indispensable in the armament of diagnostic tools of the physicians managing AIDS patients.
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Affiliation(s)
- Mahboubeh Hajiabdolbaghi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahar Ataeinia
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Ghadimi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - SeyedAhmad SeyedAlinaghi
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Omid Dadras
- Department of Global Health and Socioepidemiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mehrnaz Rasoolinejad
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
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Zanelli M, Zizzo M, Cerrone G, Ricci L, Martino G, Ascani S. Atypical mycobacteria diagnosed by bone marrow biopsy in an HIV-positive patient. Ann Hematol 2019; 99:183-184. [PMID: 31807858 DOI: 10.1007/s00277-019-03880-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/26/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Magda Zanelli
- Pathology Unit, Azienda USL-IRCCS di Reggio Emilia, v.le Risorgimento, 80, Reggio Emilia, Italy.
| | - Maurizio Zizzo
- Surgical Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Linda Ricci
- Pathology Unit, University of Siena, Siena, Italy
| | - Giovanni Martino
- Hematology Unit, CREO, Azienda Ospedaliera di Perugia, University of Perugia, Perugia, Italy
| | - Stefano Ascani
- Pathology Unit, Azienda Ospedaliera Santa Maria di Terni, University of Perugia, Terni, Italy
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7
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Zia F, Ali N. Granuloma whorls. Clin Case Rep 2019; 7:2287-2288. [PMID: 31788308 PMCID: PMC6878094 DOI: 10.1002/ccr3.2470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 08/24/2019] [Accepted: 09/17/2019] [Indexed: 11/30/2022] Open
Abstract
What is the significance of bone marrow examination in presence of peripheral cytopenias? It is still regarded as a mandatory investigation to diagnose hematological disorders. In this case, bone marrow trephine was initially done as a diagnosis of exclusion for ITP, whereas it revealed multiple granulomas suggesting mycobacterium tuberculosis infection.
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Affiliation(s)
- Farrukh Zia
- Section of Clinical Haematology, Department of OncologyAga Khan University KarachiKarachiPakistan
| | - Natasha Ali
- Section of Haematology, Department of Pathology & Laboratory Medicine/OncologyAga Khan University KarachiKarachiPakistan
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8
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Zanotti P, Chirico C, Gulletta M, Ardighieri L, Casari S, Roldan EQ, Izzo I, Pinsi G, Lorenzin G, Facchetti F, Castelli F, Focà E. Disseminated Histoplasmosis as AIDS-presentation. Case Report and Comprehensive Review of Current Literature. Mediterr J Hematol Infect Dis 2018; 10:e2018040. [PMID: 30002796 PMCID: PMC6039081 DOI: 10.4084/mjhid.2018.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/14/2018] [Indexed: 12/21/2022] Open
Abstract
Progressive disseminated histoplasmosis (PDH) is an AIDS-defining illness with a high lethality rate if not promptly treated. The wide range of its possible clinical manifestations represents the main barrier to diagnosis in non-endemic countries. Here we present a case of PDH with haemophagocytic syndrome in a newly diagnosed HIV patient and a comprehensive review of disseminated histoplasmosis focused on epidemiology, clinical features, diagnostic tools and treatment options in HIV-infected patients.
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Affiliation(s)
- Paola Zanotti
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy
| | - Claudia Chirico
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy
| | - Maurizio Gulletta
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy
| | - Laura Ardighieri
- Pathology Unit, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy
| | | | - Eugenia Quiros Roldan
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy
| | - Ilaria Izzo
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy
| | - Gabriele Pinsi
- Microbiology and Virology Unit, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy
| | - Giovanni Lorenzin
- Microbiology and Virology Unit, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy
- Institute of Microbiology and Virology, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Italy
| | - Fabio Facchetti
- Pathology Unit, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy
| | - Francesco Castelli
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy
| | - Emanuele Focà
- Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy
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9
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Ayoade F, Cotelingam J, Joel Chandranesan AS. Disseminated Mycobacterium avium-Intracellulare Complex Infection Presenting With Disseminated Intravascular Coagulation in an AIDS Patient. J Investig Med High Impact Case Rep 2017; 5:2324709617740904. [PMID: 29164156 PMCID: PMC5692144 DOI: 10.1177/2324709617740904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/20/2017] [Accepted: 09/24/2017] [Indexed: 12/01/2022] Open
Abstract
Disseminated Mycobacterium avium-intracellulare complex (MAC) infection is one of the relatively common opportunistic infections seen in severely immunocompromised AIDS patients. A constellation of clinical, laboratory, and pathological features involving multiple organ systems are often present in disseminated MAC infection but disseminated intravascular coagulation (DIC) has not been previously described in association with this condition. To our knowledge, this is the first reported case of DIC complicating disseminated MAC infection in an AIDS patient. In this article, we present the case of a 33-year-old AIDS patient with high viral load, CD4 lymphocyte count of 1/mm3, who presented with nonspecific symptoms, anemia, thrombocytopenia, and increased lactate dehydrogenase, alkaline phosphatase, and ferritin. She also had abnormal coagulation parameters and features compatible with chronic DIC. Bone marrow biopsy assisted in making the correct diagnosis. She also later grew MAC from blood and sputum cultures. There were no other factors identified after a complete workup to explain DIC in this patient. After commencement of appropriate MAC therapy, she initially had a good response with some improvement of her coagulation parameters. Few months later, however, probably attributable to poor medication compliance, her condition deteriorated with development of thromboembolism, full-fledged DIC, sepsis, and an eventual fatal outcome. This case illustrates the importance of including disseminated MAC in the differential diagnosis of DIC in an AIDS patient.
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Affiliation(s)
- Folusakin Ayoade
- Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - James Cotelingam
- Louisiana State University Health Sciences Center, Shreveport, LA, USA
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10
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Vishnu P, Aboulafia DM. Haematological manifestations of human immune deficiency virus infection. Br J Haematol 2015; 171:695-709. [PMID: 26452169 DOI: 10.1111/bjh.13783] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Early in the human immunodeficiency virus (HIV) epidemic, infected patients presented to medical attention with striking abnormalities in each of the major blood cell lineages. The reasons for these derangements remain complex and multifactorial. HIV infects multipotent haematopoietic progenitor cells and establish latent cellular reservoirs, disturbs the bone marrow microenvironment and also causes immune dysregulation. These events lead to cytokine imbalances and disruption of other factors required for normal haematopoiesis. Activation of the reticulo-endothelial system can also result in increased blood cell destruction. The deleterious effects of medications, including first and second generation anti-retroviral agents, on haematopoiesis were well documented in the early years of HIV care; in the current era of HIV-care, the advent of newer and less toxic anti-retroviral drugs have had a more beneficial impact on haematopoiesis. Due to impaired regulation of the immune system and potential side effects of one or more anti-retroviral agents, there is also an increase in coagulation abnormalities such as thromboembolism, and less frequently, acquired disorders of coagulation including thrombotic thrombocytopenic purpura, immune thrombocytopenic purpura and acquired inhibitors of coagulation. In this article we review the epidemiology and aetiology of select non-oncological haematological disorders commonly seen in people living with HIV-acquired immune deficiency syndrome.
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Affiliation(s)
- Prakash Vishnu
- Floyd & Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Floyd & Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA, USA.,Division of Hematology, University of Washington, Seattle, WA, USA
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11
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Hui YMT, Pillinger T, Luqmani A, Cooper N. Haemophagocytic lymphohistiocytosis associated with Mycobacterium tuberculosis infection. BMJ Case Rep 2015; 2015:bcr-2014-208220. [PMID: 25870214 DOI: 10.1136/bcr-2014-208220] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Haemophagocytic lymphohistiocytosis (HLH) is a rare, potentially fatal condition that can be primary or secondary. Secondary HLH can occur in association with infections, most commonly viral infections, but has also been reported in association with Mycobacterium tuberculosis (TB). Prompt identification of the underlying cause of HLH is important as it guides treatment decisions. Early initiation of appropriate treatment (eg, anti-TB treatment) reduces morbidity and mortality. We present a case of HLH associated with TB infection. Initial TB investigations were negative and standard combination chemoimmunotherapy for HLH resulted in a limited clinical response. On apparent relapse of HLH, further investigation revealed TB with changes on CT chest, granuloma on bone marrow and eventual positive TB culture on bronchoalveolar lavage. Subsequent treatment with quadruple anti-TB treatment resulted in rapid clinical response and disease remission. We advocate continued monitoring for TB infection in patients with HLH, and prophylaxis or full treatment for those at high risk.
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Affiliation(s)
- Yee Man Tracy Hui
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Toby Pillinger
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Asad Luqmani
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Nichola Cooper
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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12
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Non-tuberculous mycobacteria in children: muddying the waters of tuberculosis diagnosis. THE LANCET RESPIRATORY MEDICINE 2015; 3:244-56. [DOI: 10.1016/s2213-2600(15)00062-4] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 01/11/2015] [Accepted: 01/12/2015] [Indexed: 11/24/2022]
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13
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Quesada AE, Tholpady A, Wanger A, Nguyen AND, Chen L. Utility of bone marrow examination for workup of fever of unknown origin in patients with HIV/AIDS. J Clin Pathol 2015; 68:241-5. [PMID: 25589792 DOI: 10.1136/jclinpath-2014-202715] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIMS The utility of bone marrow aspiration and biopsy (BMAB) as a diagnostic tool in patients with HIV/AIDS and fever of unknown origin (FUO) is a subject of debate. Because highly active antiretroviral therapy has reduced incidence of opportunistic infections, it is important to reassess the efficacy of BMAB for this diagnostic purpose. To our knowledge, no such studies have been performed in Harris County which has the highest incidence of HIV in the state of Texas. METHODS We reviewed all BMABs from patients with HIV/AIDS and FUO or persistent cytopenia(s) from 2007 to 2011. RESULTS Of 57 evaluable patients, BMAB was positive in 24 samples by acid fast bacilli (AFB) or Gomori methenamine silver (GMS) stains (17.5%), presence of granuloma and/or lymphohistiocytic aggregates (31.6%), culture (21.0%) or a combination. Cultures demonstrated Mycobacterium avium/intracellulare (4), M tuberculosis (2), M gordonae (1), Histoplasma capsulatum (3) and Cryptococcus neoformans (2). There were three cases in which a pathogen was grown in culture but that had a negative of 'direct examination' on tissue sections (negative AFB and GMS special stains, no morphological evidence of granuloma/lymphohistiocytic infiltrates). CONCLUSIONS This study supports the use of diagnostic BMAB as a rapid decision-making tool in patients with HIV and FUO in the proper clinical setting. BMAB demonstrated infection-related evidence prior to positive bone marrow culture in 75% of cases. Special stains and blood cultures had similar diagnostic yield, but BMAB offers faster results. Thus, this procedure assists in clinical decision making and the refinement of treatment in a more timely manner.
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Affiliation(s)
- Andrés E Quesada
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ashok Tholpady
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Audrey Wanger
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Andy N D Nguyen
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Lei Chen
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
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14
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Shi X, Sims MD, Hanna MM, Xie M, Gulick PG, Zheng YH, Basson MD, Zhang P. Neutropenia during HIV infection: adverse consequences and remedies. Int Rev Immunol 2014; 33:511-36. [PMID: 24654626 DOI: 10.3109/08830185.2014.893301] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Neutropenia frequently occurs in patients with Human immunodeficiency virus (HIV) infection. Causes for neutropenia during HIV infection are multifactoral, including the viral toxicity to hematopoietic tissue, the use of myelotoxic agents for treatment, complication with secondary infections and malignancies, as well as the patient's association with confounding factors which impair myelopoiesis. An increased prevalence and severity of neutropenia is commonly seen in advanced stages of HIV disease. Decline of neutrophil phagocytic defense in combination with the failure of adaptive immunity renders the host highly susceptible to developing fatal secondary infections. Neutropenia and myelosuppression also restrict the use of many antimicrobial agents for treatment of infections caused by HIV and opportunistic pathogens. In recent years, HIV infection has increasingly become a chronic disease because of progress in antiretroviral therapy (ART). Prevention and treatment of severe neutropenia becomes critical for improving the survival of HIV-infected patients.
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15
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Disseminated histoplasmosis with peripheral blood spill over. Indian J Pediatr 2014; 81:313-4. [PMID: 23775202 DOI: 10.1007/s12098-013-1071-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 05/06/2013] [Indexed: 10/26/2022]
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16
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Mycobacterial bone marrow infections at a medical centre in Taiwan, 2001-2009. Epidemiol Infect 2013; 142:1524-32. [PMID: 24168831 DOI: 10.1017/s0950268813002707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Mycobacterial bone marrow (BM) infection is the most common diagnosis established by BM examinations for fever of unknown origin. In this study, clinical features and outcomes of patients who fulfilled the criteria for BM infection due to Mycobacterium tuberculosis (MTB) and non-tuberculous mycobacteria (NTM) at a medical centre in Taiwan from 2001 to 2009 were investigated. The BM histopathological findings were also analysed. A total of 24 patients (16 men, eight women) with mycobacterial BM infections were found. Of these, nine (38%) were positive for human immunodeficiency virus (HIV) and six (25%) had no pre-existing immunocompromised conditions. MTB isolates were obtained from 11 (46%) patients and NTM species were isolated from 10 (42%) patients, including M. avium complex (MAC, n = 7) and M. kansasii (n = 3). Patients with MTB infections were significantly older than those with NTM infections (60·5 vs. 47·7 years, P = 0·043) and were less likely to have a positive BM culture (45% vs. 100%, P = 0·012). The 90-day survival rates for MTB and NTM BM infections were 68% and 60%, respectively (P = 0·61). In addition, the presence of BM granulomas was significantly more common in patients with MTB BM infections than in those with NTM infections (82% vs. 30%, P = 0·030). In Taiwan, the importance of NTM was not inferior to MTB and besides MAC, M. kansasii might be an important pathogen in non-HIV-infected patients. The presence of BM granulomas and caseation provides valuable information regarding early treatment pending culture results.
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Abstract
Infectious and noninfectious skin diseases are observed in about 90% of HIV patients, and their incidence increases and is more severe as the immune system weakens. Cutaneous manifestations are considered good clinical predictors for the immunological condition of the patient with AIDS and the introduction of highly effective antiretroviral therapy totally changed the prognosis of the mycoses, among other diseases associated with AIDS, permitting longer survival and acceptable level of quality of life for these patients. This contribution describes the systemic mycoses that are more frequent in the seropositive population, that is, patients with HIV/AIDS, which are cryptococcosis, histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, sporotrichosis, penicilliosis, and aspergillosis. Their causative agents, mode of transmission, clinics, laboratorial diagnosis and therapy, in the aspects related to immunodepressed patients, are reviewed.
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Edwards S, Bergin C, Miller R. 9 Pyrexia of unknown origin (PUO). HIV Med 2011. [DOI: 10.1111/j.1468-1293.2011.00944_10.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Pande A, Bhattacharyya M, Pain S, Ghosh A, Samanta A. Diagnostic yield of bone marrow examination in HIV associated FUO in ART naïve patients. J Infect Public Health 2010; 3:124-9. [DOI: 10.1016/j.jiph.2010.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2010] [Revised: 07/12/2010] [Accepted: 07/15/2010] [Indexed: 11/24/2022] Open
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Jung W, Trümper L. [Differential diagnosis and diagnostic strategies of lymphadenopathy]. Internist (Berl) 2009; 49:305-318; quiz 319-20. [PMID: 18273586 DOI: 10.1007/s00108-008-2016-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Besides acute inflammatory swelling of a lymph node, acute lymphadenitis, enlarged lymph nodes occur in conjunction with various benign and malignant diseases. Lymphadenopathy can appear in a localized or generalized form and requires further diagnostic measures. Possible causes are primarily infectious, immunological, neoplastic, and metabolic disorders. The medical history and physical examination provide the first clues to the diagnosis. Localized swollen glands often have an infectious etiology so that the first step is to identify the possible focus of infection. Generalized lymphadenopathy is frequently a sign of a hematological systemic disease, particularly in adults. Therefore, in every case of lymphadenopathy persisting for more than 1 month, invasive diagnostic procedures are indicated to rule out a malignant cause. The aim should be to perform a histological analysis; excision of entire lymph nodes is exigent, especially for the work-up of lymphoma. In cases of malignant lymphoma, staging examinations should subsequently be conducted to assess the prognosis and formulate a treatment plan.
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Affiliation(s)
- W Jung
- Abteilung Hämatologie und Onkologie, Zentrum Innere Medizin, Universitätsmedizin der Georg-August-Universität Göttingen, 37099, Göttingen
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Gupta R, Setia N, Arora P, Singh S, Singh T. Hematological profile in pyrexia of unknown origin: role of bone marrow trephine biopsy vis-à-vis aspiration. ACTA ACUST UNITED AC 2009; 13:307-12. [PMID: 18854095 DOI: 10.1179/102453308x343446] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Bone marrow examination, by aspiration and/or trephine biopsy, is an important procedure in arriving at a diagnosis for long-duration febrile illness. The role of trephine biopsy in immunocompromised host, especially HIV-positive patients, has been well studied in the literature. However, its utility in immunocompetent patients is still shrouded by controversy. Thus, the authors attempted to evaluate the utility of marrow aspirate vis-à-vis trephine biopsy in establishing a diagnosis in cases of pyrexia of unknown origin in immunocompetent individuals, along with an analysis of haematological alterations in these patients. MATERIALS AND METHODS Over a period of 8 years, 121 patients with pyrexia of unknown origin underwent both bone marrow aspiration and trephine biopsy as a part of diagnostic work-up. These cases were reviewed for their clinical data and hematological findings, including detailed morphological features in aspiration smears and trephine biopsies. Bone marrow aspiration and biopsy were compared for their diagnostic efficacy in these patients. RESULTS A wide age range (2-65 years) was noted with a slight male predominance (2 : 1). Anemia was the most common feature in peripheral blood findings, seen in 97.5% of patients. Bone marrow aspiration was diagnostic in only 16.5% of cases, which revealed leishmaniasis or pure red cell aplasia. Granulomas were infrequent in marrow aspiration smears, as only two cases (1.6%) showed ill defined epithelioid cell collections. Compared to this, trephine biopsy offered a diagnosis in 76% of the cases. Granulomas were a frequent finding in the trephine biopsy, being present in 70% of the cases included. Additional cases diagnosed on biopsy (over those diagnosed with aspiration smears) included lymphoma, tuberculosis, fungal infection, sarcoidosis and hypocellular marrow. CONCLUSION Bone marrow trephine biopsy is an important adjunct to aspiration in arriving at an aetiological diagnosis of patient with long-duration febrile illness, and should be routinely performed in such cases. The presence of granulomas in trephine biopsy increases the likelihood of an etiologic diagnosis in these patients.
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Affiliation(s)
- Ruchika Gupta
- Department of Pathology, Maulana Azad Medical College, New Delhi, India.
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22
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Hot A, Schmulewitz L, Viard JP, Lortholary O. Fever of unknown origin in HIV/AIDS patients. Infect Dis Clin North Am 2008; 21:1013-32, ix. [PMID: 18061087 DOI: 10.1016/j.idc.2007.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fever of unknown or uncertain origin (FUO) constitutes a common clinical challenge in patients infected with HIV. It is usually caused by disseminated opportunistic infection, and the relative frequency of each cause of FUO is influenced by multiple factors including CD4 count, geographic setting, and local prevalences of infectious agents, which may provide clues to the diagnosis. Infections presenting as FUO in the HIV population occur most often in the late stages of the disease and high diagnostic suspicion for mycobacterial disease should be maintained when evaluating these patients, particularly in areas of high prevalence. This article discusses the causes, diagnosis, and treatment of FUO in HIV-infected individuals.
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Affiliation(s)
- Arnaud Hot
- Université Paris V, Service des Maladies Infectieuses et Tropicales, Centre d'Infectiologie Necker-Pasteur, Hôpital Necker-Enfants Malades, 149 rue de Sèvres, 75743 Paris Cedex 15, France
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Gazzola L, Zanini F, Zerbi P, Franzetti F, Gori A. The usefulness of PCR assay in diagnosing disseminated mycobacterial infection in AIDS patients. Eur J Clin Microbiol Infect Dis 2007; 27:163-6. [PMID: 17999096 DOI: 10.1007/s10096-007-0407-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2007] [Accepted: 09/29/2007] [Indexed: 12/01/2022]
Affiliation(s)
- L Gazzola
- Clinic of Infectious Diseases, San Paolo Hospital, University of Milan, Via A. di Rudinì, 8, 20142 Milan, Italy.
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Weydert JA, Van Natta TL, DeYoung BR. Comparison of fungal culture versus surgical pathology examination in the detection of Histoplasma in surgically excised pulmonary granulomas. Arch Pathol Lab Med 2007; 131:780-3. [PMID: 17488166 DOI: 10.5858/2007-131-780-cofcvs] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2006] [Indexed: 11/06/2022]
Abstract
CONTEXT Granulomatous pulmonary nodules are common in areas endemic for Histoplasma infection, and may require surgical excision to exclude neoplasia. Surgeons may elect to routinely send material directly to the clinical microbiology laboratory for fungal and mycobacterial cultures. OBJECTIVE To determine if tissue from surgically excised pulmonary granulomatous nodules removed from patients in a geographic area endemic for Histoplasma infection should be routinely submitted for fungal culture. DESIGN Retrospective review and comparison of surgical pathology histochemical findings and clinical microbiology results of 30 surgical (wedge) lung excisions that demonstrated granulomatous nodule at the time of frozen section. RESULTS Twenty cases demonstrated fungal organisms consistent with Histoplasma species via histochemical fungal stains. Of these 20 cases, 17 were tested in the microbiology laboratory using direct smear examination and fungal culture; Histoplasma was detected in 1 case (1/17). Eight cases revealed no organisms by surgical pathology. Of these, 6 were tested in the microbiology laboratory, and all 6 were negative by culture and direct smear (0/6). The remaining 2 cases demonstrated organisms other than Histoplasma by surgical pathology examination. CONCLUSIONS Surgical pathology examination of granulomatous pulmonary nodules detected Histoplasma organisms with greater sensitivity than culture and direct smear. There were no false-negative surgical pathology diagnoses when compared with microbiological results. These findings suggest that it is not necessary to routinely send material from solitary pulmonary granulomas for fungal culture when the material is removed from immunocompetent patients in a geographic area endemic for histoplasmosis.
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Affiliation(s)
- Jamie A Weydert
- University of Iowa Carver College of Medicine, Department of Pathology, 5239C RCP, 200 Hawkins Dr, Iowa City, IA 52242, USA.
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Couppié P, Aznar C, Carme B, Nacher M. American histoplasmosis in developing countries with a special focus on patients with HIV: diagnosis, treatment, and prognosis. Curr Opin Infect Dis 2006; 19:443-9. [PMID: 16940867 DOI: 10.1097/01.qco.0000244049.15888.b9] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Histoplasmosis due to Histoplasma capsulatum var capsulatum is a frequent systemic fungal infection in the Americas. Diagnostic and therapeutic options differ between North and South America. Disseminated histoplasmosis is an AIDS-defining infection. Prognostic factors of potentially severe presentations must be evaluated in order to facilitate the initial therapeutic choice. RECENT FINDINGS Patients with HIV with disseminated infections presenting with severe pulmonary and renal impairment have a poor prognosis. Cutaneous presentations are more frequent in HIV patients in South America than in North America. A murine model has shown that South American isolates have a greater virulence that North American isolates. These differences are due in part to diagnostic delays in resource-poor countries. SUMMARY Direct examination of May-Grünwald-Giemsa-stained smears or tissues in suspected histoplasmosis is a simple means of confirming the diagnosis in resource-poor settings. Studies of prognostic factors should further refine indication criteria to guide first-line treatment choice between amphotericin B and itraconazole. The association of tuberculosis and histoplasmosis is frequent in HIV patients and presents diagnostic and therapeutic challenges that may be difficult to resolve in resource-poor settings. It is important that affordable generic drugs for treating histoplasmosis be made widely available in resource-poor countries.
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Affiliation(s)
- Pierre Couppié
- Service de Dermatologie, French Guiana, Centre Hospitalier de Cayenne, Centre Hospitalier de Cayenne, Cayenne, French Guiana.
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Al-Agha OM, Mooty M, Salarieh A. A 43-Year-Old Woman With Acquired Immunodeficiency Syndrome and Fever of Undetermined Origin. Arch Pathol Lab Med 2006; 130:120-3. [PMID: 16390228 DOI: 10.5858/2006-130-120-aywwai] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Osama M Al-Agha
- Department of Pathology, State University of New York, Downstate Medical Center, Brooklyn, New York 11203, USA.
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Riley RS, Hogan TF, Pavot DR, Forysthe R, Massey D, Smith E, Wright L, Ben-Ezra JM. A pathologist's perspective on bone marrow aspiration and biopsy: I. Performing a bone marrow examination. J Clin Lab Anal 2004; 18:70-90. [PMID: 15065211 PMCID: PMC6807972 DOI: 10.1002/jcla.20008] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The bone marrow aspirate and biopsy is an important medical procedure for the diagnosis of hematologic malignancies and other diseases, and for the follow-up evaluation of patients undergoing chemotherapy, bone marrow transplantation, and other forms of medical therapy. During the procedure, liquid bone marrow is aspirated from the posterior iliac crest or sternum with a special needle, smeared on glass microscope slides by one of several techniques, and stained by the Wright-Giemsa or other techniques for micro-scopic examination. The bone marrow core biopsy is obtained from the posterior iliac crest with a Jamshidi or similar needle and processed in the same manner as other surgical specimens. Flow cytometric examination, cytochemical stains, cytogenetic and molecular analysis, and other diagnostic procedures can be performed on bone marrow aspirate material, while sections prepared from the bone marrow biopsy can be stained by the immunoperoxidase or other techniques. The bone marrow procedure can be performed with a minimum of discomfort to the patient if adequate local anesthesia is utilized. Pain, bleeding, and infection are rare complications of the bone marrow procedure performed at the posterior iliac crest, while death from cardiac tamponade has rarely occurred from the sternal bone marrow aspiration. The recent development of bone marrow biopsy needles with specially sharpened cutting edges and core-securing devices has reduced the discomfort of the procedure and improved the quality of the specimens obtained.
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Affiliation(s)
- Roger S Riley
- Department of Pathology, Medical College of Virginia Campus of Virginia Commonwealth University Richmond, Virginia, USA.
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Hematologic Findings in Mycobacterial Infections Among Immunosuppressed and Immunocompetent Patients. Tuberculosis (Edinb) 2004. [DOI: 10.1007/978-3-642-18937-1_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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