Bone marrow necrosis

Abstract

A 64-year-old woman was admitted with a high fever and generalized bone pain. There was systemic lymphadenopathy and hepatosplenomegaly. Laboratory examination showed pancytopenia and high levels of lactate dehydrogenase (13 087 U/l) and alkaline phosphatase (1576 U/l). Bone marrow aspiration from both the sternum and iliac crest yielded necrotic marrow with smudge cells in a background of acidophilic granular material (top left, Wright’s stain). A section of the marrow clots showed shadows of cells with dimly stained nuclei that were reminiscent of tumour cells (bottom left, haematoxylin and eosin). In view of the severity of the illness, combination chemotherapy (cyclophosphamide, vincristine, methotrexate, prednisolone and procarbazine) was immediately started. This resulted in rapid regression of the organomegaly. However, after 1 month, lymph nodes began to regrow with 40% lymphoma-like cells in the peripheral blood. Lymph node biopsy was scheduled but the patient died of intracranial haemorrhage. Postmortem examination showed T-cell lymphoma involving many organs including the bone marrow. Bone marrow necrosis persisted multifocally with areas of intact lymphoma cells (right, haematoxylin and eosin). Bone marrow necrosis is a grave prognostic sign, as most cases are associated with either haematologic malignancy or metastatic cancer. It is likely that the expansive growth of tumour cells within the non-compliant space impedes blood flow, causing ischaemic necrosis of the marrow.