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Maccio U, Gianolio A, Rets AV. Granulomas in bone marrow biopsies: clinicopathological significance and new perspectives. J Clin Pathol 2023; 77:8-15. [PMID: 37640519 DOI: 10.1136/jcp-2023-209104] [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: 08/01/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
Abstract
Bone marrow granulomas in trephine biopsies are a rare and usually incidental finding. Possible causes include infectious (especially tuberculous and rarer non-tuberculous mycobacteria, but also many other bacterial, viral, fungal and parasitic agents) and non-infectious causes (especially medications, autoimmune disease, sarcoidosis, haematological and non-haematological malignancy). Necrotising granulomas are generally suggestive of an infectious aetiology (tuberculosis being the most common), whereas fibrin ring granulomas are associated with Q-fever and Epstein Barr Virus, although exceptions are possible. Every case suspicious for infectious aetiology should undergo further analysis like special staining (Ziehl-Neelsen for acid-fast rods) or molecular studies. The histomorphology should always be clinically correlated. In cases in which no infectious cause can be identified, untargeted metagenomics may represent a valid diagnostic tool that may become standard in the near future for bone marrow diagnostics. In this review, we have analysed the published data from 1956 up to today, and we report aspects of epidemiology, aetiology, diagnostic algorithms, differential diagnosis and the role of metagenomics in bone marrow biopsies with granulomas.
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Affiliation(s)
- Umberto Maccio
- Pathology and Molecular Pathology, University Hospital Zurich, Zürich, Switzerland
| | - Alessandra Gianolio
- Department of Medical Sciences, University of Turin, Torino, Piemonte, Italy
| | - Anton V Rets
- Department of Hematopathology, ARUP Laboratories Inc, Salt Lake City, Utah, USA
- Pathology, The University of Utah School of Medicine, Salt Lake City, Utah, USA
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Ghosh K, Shome DK, Kulkarni B, Ghosh MK, Ghosh K. Fibrosis and bone marrow: understanding causation and pathobiology. J Transl Med 2023; 21:703. [PMID: 37814319 PMCID: PMC10561412 DOI: 10.1186/s12967-023-04393-z] [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: 05/10/2023] [Accepted: 07/28/2023] [Indexed: 10/11/2023] Open
Abstract
Bone marrow fibrosis represents an important structural change in the marrow that interferes with some of its normal functions. The aetiopathogenesis of fibrosis is not well established except in its primary form. The present review consolidates current understanding of marrow fibrosis. We searched PubMed without time restriction using key words: bone marrow and fibrosis as the main stem against the terms: growth factors, cytokines and chemokines, morphology, megakaryocytes and platelets, myeloproliferative disorders, myelodysplastic syndrome, collagen biosynthesis, mesenchymal stem cells, vitamins and minerals and hormones, and mechanism of tissue fibrosis. Tissue marrow fibrosis-related papers were short listed and analysed for the review. It emerged that bone marrow fibrosis is the outcome of complex interactions between growth factors, cytokines, chemokines and hormones together with their facilitators and inhibitors. Fibrogenesis is initiated by mobilisation of special immunophenotypic subsets of mesenchymal stem cells in the marrow that transform into fibroblasts. Fibrogenic stimuli may arise from neoplastic haemopoietic or non-hematopoietic cells, as well as immune cells involved in infections and inflammatory conditions. Autoimmunity is involved in a small subset of patients with marrow fibrosis. Megakaryocytes and platelets are either directly involved or are important intermediaries in stimulating mesenchymal stem cells. MMPs, TIMPs, TGF-β, PDGRF, and basic FGF and CRCXL4 chemokines are involved in these processes. Genetic and epigenetic changes underlie many of these conditions.
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Affiliation(s)
- Kanjaksha Ghosh
- National Institute of Immunohaematology, 13 Th Fl KEM Hospital, Parel, Mumbai, 400012, India.
| | - Durjoy K Shome
- Department of Pathophysiology, American University of Antigua College of Medicine, Coolidge, Antigua and Barbuda
| | - Bipin Kulkarni
- Department of Molecular Biology and Haemostasis, National Institute of Immunohaematology, 13Th Fl KEM Hospital, Parel, Mumbai, 400012, India
| | - Malay K Ghosh
- Department of Haematology, Nilratan Sarkar Medical College, Kolkata, 700014, West Bengal, India
| | - Kinjalka Ghosh
- Department of Clinical Biochemistry, Tata Medical Centre and Homi Bhaba National Institute, Parel, Mumbai, 400012, India
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Caballero JC, Askari E, Carrasco N, Piris MA, Perez de Camino B, Pardo L, Cornago J, Lopez-Lorenzo JL, Llamas P, Solan L. Invasive Cutaneous Candidiasis, Autoimmune Hemolytic Anemia and Pancytopenia: A Challenging Scenario for Waldenström Macroglobulinemia in an Elderly Patient. Biomedicines 2023; 11:biomedicines11041007. [PMID: 37189625 DOI: 10.3390/biomedicines11041007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/10/2023] [Accepted: 03/21/2023] [Indexed: 05/17/2023] Open
Abstract
Waldenström macroglobulinemia (WM) is a slowly progressive hematologic malignancy that usually responds rapidly to treatment. Being a lymphoplasmacytoid neoplasm, it is associated with a monoclonal IgM component, which may be associated with multiple manifestations and symptoms. We report the case of a 77-year-old woman diagnosed with WM following the development of severe and sudden pancytopenia associated with a cold agglutinin syndrome. In order to treat the WM and the underlying hemolysis, treatment with rituximab, corticosteroids and cyclophosphamide was started. Despite the improvement in hemolysis parameters, pancytopenia persisted, and we started a second line with ibrutinib. During treatment the patient developed an uncommon invasive fungal infection (IFI) with bone marrow granulomatosis and myelofibrosis. This case shows an unusual clinical course with a poor hematopoietic response to treatment and a large number of intercurrent complications.
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Affiliation(s)
- Juan Carlos Caballero
- Hematology Department, Fundacion Jimenez Diaz University Hospital, 28040 Madrid, Spain
| | - Elham Askari
- Hematology Department, Fundacion Jimenez Diaz University Hospital, 28040 Madrid, Spain
| | - Nerea Carrasco
- Infectious Diseases Department, Fundacion Jimenez Diaz University Hospital, 28040 Madrid, Spain
| | - Miguel Angel Piris
- Pathology Department, Fundacion Jimenez Diaz University Hospital, 28040 Madrid, Spain
| | | | - Laura Pardo
- Hematology Department, Fundacion Jimenez Diaz University Hospital, 28040 Madrid, Spain
| | - Javier Cornago
- Hematology Department, Fundacion Jimenez Diaz University Hospital, 28040 Madrid, Spain
| | | | - Pilar Llamas
- Hematology Department, Fundacion Jimenez Diaz University Hospital, 28040 Madrid, Spain
| | - Laura Solan
- Hematology Department, Fundacion Jimenez Diaz University Hospital, 28040 Madrid, Spain
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Nussbaum EZ, Patel KK, Assi R, Raad RA, Malinis M, Azar MM. Clinicopathologic Features of Tissue Granulomas in Transplant Recipients: A Single Center Study in a Nontuberculosis Endemic Region. Arch Pathol Lab Med 2020; 145:988-999. [PMID: 33290524 DOI: 10.5858/arpa.2020-0271-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— There is a paucity of literature about tissue granulomas in transplant patients. OBJECTIVE.— To characterize the clinicopathologic features of granulomas in this population and develop a clinically judicious approach to their evaluation. DESIGN.— We performed chart reviews of solid organ and allogeneic hematopoietic stem cell transplant recipients at Yale New Haven Hospital to identify patients with granulomas on biopsy obtained pathologic specimens. Pretransplant and posttransplant specimens were included. Data points included demographics, clinical presentation, epidemiologic risk factors, biopsy indication, location and timing, immunosuppression, histopathology, microbiology, and associated clinical diagnosis. Granuloma-related readmissions and mortality were recorded at 1, 3, and 12 months. RESULTS.— Biopsy proven granulomas were identified in 56 of 2139 (2.6%) patients. Of 56, 16 (29%) were infectious. Common infectious etiologies were bartonellosis (n = 3) and cytomegalovirus hepatitis (n = 3). Tuberculosis was not identified. Clinical symptoms prompted tissue biopsy in 27 of 56 (48.2%) cases while biopsies were obtained for evaluation of incidental findings or routine disease surveillance in 29 of 56 (51.8%). Presence of symptoms was significantly associated with infectious etiologies; 11 of 27 (40.7%) symptomatic patients compared with 5 of 29 (17.2%) asymptomatic patients had infectious causes. One death from granulomatous cryptogenic organizing pneumonia occurred. In pretransplant asymptomatic patients, no episodes of symptomatic disease occurred posttransplantation. CONCLUSIONS.— Granulomas were uncommon in a large transplant population; most were noninfectious but presence of symptoms was associated with infectious etiologies. Granulomas discovered pretransplant without clear infectious etiology likely do not require prolonged surveillance after transplantation. Symptomatology and epidemiologic risks factors should guide extent of microbiologic evaluation.
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Affiliation(s)
| | | | - Roland Assi
- Department of Surgery (Assi), New Haven, Connecticut
| | - Rita Abi Raad
- Department of Pathology (Raad), New Haven, Connecticut
| | - Maricar Malinis
- From the Department of Internal Medicine (Nussbaum, Malinis, Azar), New Haven, Connecticut.,The Section of Infectious Diseases (Malinis, Azar), New Haven, Connecticut
| | - Marwan M Azar
- From the Department of Internal Medicine (Nussbaum, Malinis, Azar), New Haven, Connecticut.,The Section of Infectious Diseases (Malinis, Azar), New Haven, Connecticut
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Modi T, Maniam G, Quirch M, Warraich I, Rehman S. Extrapulmonary sarcoidosis in an atypical patient demographic. Proc (Bayl Univ Med Cent) 2020; 34:151-152. [PMID: 33456182 DOI: 10.1080/08998280.2020.1824963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Although it typically presents with cough and dyspnea due to pulmonary involvement, sarcoidosis is a multisystem granulomatous disease and therefore may present with extrapulmonary manifestations. Cutaneous manifestations are common, while hepatic sarcoidosis is uncommon and osseous manifestations are exceedingly rare. This article describes osseous, hepatic, and cutaneous manifestations due to sarcoidosis. The patient was diagnosed with sarcoidosis, treated with a dynamic hip screw implant with a derotational screw, and discharged on a new medication regimen: vitamin D, calcium supplements, alendronate, methotrexate, and hydroxychloroquine.
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Affiliation(s)
- Trisha Modi
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Ganesh Maniam
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Miguel Quirch
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Irfan Warraich
- Department of Pathology, Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Shabnam Rehman
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
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Hong FS, Fox LC, Chai KL, Htun K, Clucas D, Morgan S, Cole-Sinclair MF, Juneja S. Role of bone marrow biopsy for fever of unknown origin in the contemporary Australian context. Intern Med J 2020; 49:850-854. [PMID: 30350441 DOI: 10.1111/imj.14147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 09/23/2018] [Accepted: 10/15/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bone marrow biopsy (BMB) is an accepted investigation in fever of unknown origin (FUO) to uncover haematological malignancies, such as lymphoma, and sometimes infections. With the advance in imaging modalities, such as 18-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) to identify the focus of lymphoma, BMB may not contribute to the diagnosis when there are no other clinical features to suggest an underlying haematological disease. AIM To investigate the utility of BMB in determining the cause of FUO, when there are no other indications for BMB. METHODS Medical records of adult patients who had BMB performed for FUO or febrile illness from 1 January 2005 to 31 December 2014 in four metropolitan tertiary hospitals in Melbourne, Australia were reviewed. Patients with other concurrent indications for BMB, known human immunodeficiency virus infection and previously diagnosed connective tissue diseases were excluded. RESULTS Seventy-three patients were included in the study. Fifty-one patients had a final diagnosis for fever (systemic inflammatory diseases, infective, malignancy or other) while 22 patients had no diagnoses. In only 10 patients (13.7%) did BMB contribute to the diagnosis, finding either malignancy or granulomata. However, all these diagnoses could have been made without BMB. Two patients with diffuse large B-cell lymphoma had normal BMB. FDG-PET was helpful in making a diagnosis in eight (25%) out of 32 patients. CONCLUSION Performing BMB in patients with FUO and no other haematological abnormalities is of very limited value, and other investigations, such as FDG-PET, may be more likely to help establish a definitive diagnosis.
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Affiliation(s)
- Frank S Hong
- Department of Laboratory Haematology, Austin Health, Victoria, Australia
| | - Lucy C Fox
- Department of Laboratory Haematology, Austin Health, Victoria, Australia
| | - Khai Li Chai
- Laboratory Haematology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Kay Htun
- Laboratory Haematology, Alfred Health, Victoria, Australia
| | - Danielle Clucas
- Diagnostic Haematology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Susan Morgan
- Laboratory Haematology, Alfred Health, Victoria, Australia
| | | | - Surender Juneja
- Diagnostic Haematology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Sai SK, Padhi S, Varghese RGB, Kanungo R, Basheer A, Iqbal N. Diagnostic utility of bone marrow examination in evaluation of fever: a descriptive study on 98 immunocompetent adults from a tertiary care institute in south India. Trop Doct 2019; 49:88-96. [PMID: 30614411 DOI: 10.1177/0049475518822844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Five-year clinico-laboratory data from 99 (one HIV seropositive) adults (mean age = 41.3 ± 20.4 years) who underwent bone marrow examination for fever persisting for ≥ 1 week were analysed and correlated with microbiological characteristics. Infections, reactive marrow changes and haematolymphoid malignancies were most commonly associated with fever. A high concordance rate of 71% was noted between aspiration and trephine biopsies. Bone marrow granulomas (BMG) were seen exclusively on sections and were most commonly of tubercular and typhoidal in origin (two Salmonella Typhi, one Salmonella Paratyphi A). The common aetiologies associated with fever and cytopenia(s) were BMG, acute leukaemia and haemophagocytic lymphohistiocytosis (HLH; n = 3). The yield from bone marrow culture was inferior compared to other body fluids. In conclusion, bone marrow histology is superior to smears in the evaluation of prolonged fever. Marrow culture may not be useful in immunocompetent individuals other than if Salmonellosis is suspected.
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Affiliation(s)
- Sri Krishna Sai
- 1 Junior Resident, Department of Pathology, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Somanath Padhi
- 2 Associate Professor, Department of Pathology, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Renu G Boy Varghese
- 3 Professor and Head, Department of Pathology, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Reba Kanungo
- 4 Professor and Head, Department of Microbiology, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Aneesh Basheer
- 5 Associate Professor, Department of General Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Nayyar Iqbal
- 5 Associate Professor, Department of General Medicine, Pondicherry Institute of Medical Sciences, Pondicherry, India
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