To evaluate the role of bone marrow aspiration and bone marrow biopsy in pancytopenia

Concomitant manifestations of systemic lupus erythematosus flare-up and nodal marginal zone B-cell lymphoma in a 41-year-old male patient: A challenging case report

Key Clinical Message

Malignancy may be a possible cause of systemic lupus erythematosus (SLE) flare-ups, and it is necessary to consider it in the context of treatment resistance. In this case, we present a challenging instance of concomitant nodal marginal zone B-cell lymphoma (NMZL) and SLE flare-up in a 41-year-old male patient.

Abstract

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that can cause various symptoms and affect multiple organs in the body. It is also associated with the development of malignancies, especially lymphomas. This case report discusses a patient who experienced a flare-up of SLE along with hypercalcemia, which led to the diagnosis of nodal marginal zone B-cell lymphoma (NMZL). This is the first case of its kind to be reported. A 41-year-old man with a 10-year history of SLE and antiphospholipid syndrome (APS) was referred to our center due to several symptoms, including fatigue, oral lesions, dyspnea, bilateral wrist pain and inflammation, mild pericardial effusion, organ enlargement, pancytopenia, high erythrocyte sedimentation (ESR) level, high anti-double stranded DNA (anti-dsDNA) level, low complement level, resistant hypercalcemia, and high brain natriuretic peptide (pro-BNP) level. After further testing, it was discovered that the patient had NMZL, which was the ultimate diagnosis. He underwent six cycles of the R-CHOP chemotherapy regimen, and his clinical and laboratory conditions improved during follow-ups. The initial case of SLE flare-up, with concomitant NMZL is being reported as the final diagnosis. In simpler terms, it is possible for lymphoma to manifest as a potential cause of SLE flare-ups, and clinicians should be mindful that they need to consider malignant conditions when faced with treatment resistance.

HIV-positive patients presenting with peripheral blood cytopenias: is bone marrow assessment a priority?

Introduction

Hematologic abnormalities are frequent among persons living with HIV (PLWH). The bone marrow aspirate (BMA) and biopsy (BMB) are commonly performed in the diagnostic approach of patients with unexplained cytopenias. Changes in antiretrovirals, supportive therapy and increased life expectancy have modified the distribution and etiology of cytopenias, questioning their use. Our aim was to analyze the diagnostic yield of BMA, BMB and marrow cultures for the evaluation of cytopenias in PLWH.

Methods

This was a retrospective cohort of ≥ 18-year-old PLWH undergoing bone marrow assessment (MA) for the evaluation of cytopenias between January 2002 and December 2015.

Results

A total of 236 cytopenic events were analyzed, 47.9% being PLWH who had a longstanding diagnosis (≥ 1 year). Adherence to antiretrovirals was 63.5%. Anemia was seen in 91.9% and pancytopenia in 39%. Common presentations included fever (52.1%), weight loss (42.8%) and adenopathies (28.8%). Median days from detection to MA was 5 (0 – 63 days). Most common etiologies were non-HIV infectious diseases (31.4%) and benign/malignant hematologic diseases (26.3%). The diagnostic yield was 16.1% for BMA, 20.3% for BMB, 30.5% for both and 35.6% when cultures were added. Patients most likely to have conclusive MA were those with moderate/severe thrombocytopenia (p = 0.007). Fever, splenomegaly, and low CD4+ counts were associated with infectious etiologies, while hematologic diagnoses were related to the presence of adenopathies.

Conclusion

As a minimally invasive intervention, the MA has a high yield for identifying the etiology of cytopenic events in PLWH, being conclusive in one in three patients. Early performance could lead to prompt diagnosis and timely therapy initiation.