Bone Marrow Granulomas Research Articles

Red herrings and zebras and TB, oh my! Unexpected bone marrow presentation of Mycobacterium tuberculosis

Abstract Introduction/Objective Epithelioid granulomas are uncommon and non-specific findings in bone marrow samples, and should prompt additional testing for appropriate diagnosis and treatment, especially in the immunocompromised patient. The differential diagnosis for bone marrow granulomas includes infections, neoplasia, autoimmune disease, sarcoidosis, and drug/therapy reaction. Although bone marrow workup to delineate the cause of granulomas should include staining to rule out both infection and lymphoma, morphologic review is often inconclusive. Final diagnosis requires clinical consultation and additional testing. Methods/Case Report A 76-year-old male was admitted to the hospital from the emergency department for a level 2 trauma after being found on the ground ~3 hours after a fall. The patient reported a recent increasing frequency of falls with associated weakness, as well as an almost 30 lb weight loss over the last 3.5 months and low grade fevers over several weeks. His past medical history was significant for treatment for urothelial carcinoma with transurethral resection and BCG therapy, hypertension, coronary artery disease, and peripheral vascular disease. Imaging showed hepatosplenomgaly, suspicious for early cirrhosis, and mild peripancreatic lymphadenopathy. Initial laboratory abnormalities demonstrated mild anemia, low albumin, and mild increase in ALT, AST, and alkaline phosphotase. Initial Infectious Diseases workup was negative for causative etiology (blood cultures, tick-borne parasites, and respiratory pathogens). Patient symptoms did not improve and cytopenias worsened. A bone marrow biopsy showed multiple non-necrotizing epithelioid granulomas. Despite low clinical concern for infectious etiology, mycobacteria blood culture isolated Mycobacterium tuberculosis complex. Final results were available 112 days after specimen collection. Results (if a Case Study enter NA) NA Conclusion Although tuberculosis is commonly associated with granulomatous pathology, infection is very uncommon in North American patients who have not traveled and alternative diagnoses might initially be favored. A high suspicion for mycobacterial infections is essential for diagnosis even in low-incidence populations with no known exposure or risk factor(s).

A Rare Case Report of Amiodarone-Induced Bone Marrow Granuloma

A Rare Case Report of Amiodarone-Induced Bone Marrow Granuloma

A Rare Presentation of Pancytopenia - Amiodarone-Induced Bone Marrow Granuloma

Introduction: Amiodarone is a widely used antiarrhythmic medication associated with a various range of side effects, such as thyroiditis, pneumonitis, and hepatitis. Additionally, although extremely rare, amiodarone has been reported to induce bone marrow granuloma, leading to hematologic disorders. This abstract illustrates the case of amiodarone-induced bone marrow granuloma resulting from unopposed intake of the medication. Case presentation: A 67-year-old male with a known history of iron deficiency and Vitamin B12 deficiency was referred to the hematology/oncology clinic from his primary care clinic due to persistent pancytopenia despite receiving iron and vitamin supplements. Three months before this presentation, the patient underwent EGD and colonoscopy, which did not reveal any gastrointestinal neoplasm. He denied experiencing other symptoms, such as fever, chill, nausea, or vomiting. Both his vital signs and physical examinations were unremarkable. Routine lab results showed pancytopenia, with a hemoglobin level of 11.2, MCV of 71, WBC of 2.6, and platelet of 128. The peripheral blood smear did not demonstrate any blasts or atypical leukocytes. Flow cytometry was negative for abnormal cellular populations. However, the bone marrow biopsy revealed a hypercellular marrow with numerous scattered non-necrotizing granulomas without blasts or atypical cells. A broad range of diagnoses was considered encompassing sarcoidosis, malignancy, infective diseases, and drug reactions. Chest, abdomen, and pelvis CT showed no evidence of malignancy or sarcoidosis. The patient was referred to the infectious disease department to exclude undiagnosed infectious causes. An extensive work-up ensued, including tick-borne diseases, fungal infections, tuberculosis, hepatitis, CMV, and HIV, all of which yielded negative results. The patient's medication list was reviewed to evaluate any potential medication-related adverse effects. Notably, it revealed that the patient had been self-administering amiodarone 200mg once daily for the past 18 months without appropriate cardiology supervision, which was prescribed to manage frequent premature ventricular complexes (PVCs). This situation occurred as a result of the cardiologist leaving the area, which led to a disruption in the follow-up care. Consequently, the patient was presumably diagnosed with amiodarone-induced bone marrow granuloma and was referred to cardiology for further management of amiodarone and PVC. Management: Amiodarone was discontinued and was switched to sotalol by cardiology. Simultaneously, the patient continued to follow hematology/oncology for regular follow-up of CBC. Following the cessation of amiodarone, the patient's pancytopenia gradually improved over time. Discussion: Amiodarone-induced bone marrow granuloma is an extremely rare adverse effect, and its incidence remains unknown due to limited information. However, several case reports documented a similar side effect associated with amiodarone. Typically, bone marrow biopsy reveals noncaseating granuloma, and patients may exhibit various forms of cytopenia. Patients with this condition have shown improvement in cytopenia after the discontinuation of amiodarone. Also, it was observed that granuloma of the bone marrow partially or completely resolves following the discontinuation. However, considering the wide array of potential causes of bone marrow granuloma, including infectious diseases, malignancy, or inflammatory diseases, physicians must thoroughly investigate and exclude other plausible causes before making the diagnosis. Nevertheless, it is crucial for physicians to include amiodarone as the differential diagnosis of pancytopenia as it can be easily reversed by the discontinuation of amiodarone.

A case of VEXAS syndrome presenting with unusual bone marrow granulomas: a diagnostic dilemma

BackgroundVEXAS is a recently described inflammatory disease caused by mutations in the UBA1 gene. Symptoms are diverse and include fevers, cartilaginous inflammation, lung inflammation, vasculitis, neutrophilic dermatoses, and macrocytic anemia. Cytoplasmic inclusions in myeloid and erythroid progenitors in the bone marrow are a hallmark feature. Here we report the first case of VEXAS with non-caseating granulomas in the bone marrow.Case presentationA 62-year-old Asian male presented with fevers, erythema nodosum, inflammatory arthritis, and periorbital inflammation. Labs were significant for persistently elevated inflammatory markers and macrocytic anemia. Over the years his symptoms and inflammatory markers only improved with glucocorticoids and recurred when prednisone dose was lowered below 15–20 mg daily. He underwent bone marrow biopsy showing non-caseating granulomas and PET scan showing hilar/mediastinal lymphadenopathy. He was initially diagnosed with IgG4-related disease (treated with rituximab) and later sarcoidosis (treated with infliximab). After failing these agents, the possibility of VEXAS was considered and later confirmed by molecular testing.ConclusionsTo the best of our knowledge, this is the first observation of non-caseating granulomas in VEXAS, a cautionary reminder of its non-specificity since misinterpretation can lead to diagnostic delay. VEXAS should be in the differential in patients with symptoms of chronic inflammation responding positively to steroids (but not to B-cell depletion or TNF inhibition), which is in line with previous literature.

Sarcoidosis presenting with bicytopenia due to bone marrow granuloma

A 55-year-old homemaker presented with low-grade fever, fatigue, and loss of weight for 2 months. She had hepatosplenomegaly, mediastinal lymphadenopathy, cytopenias, hypercalcemia with normal parathormone, and noncaseating granulomas in bone marrow and lymph node biopsy. The patient was diagnosed to have sarcoidosis with bone marrow involvement (histopathology showing noncaseating granuloma and high serum angiotensin-converting enzyme after ruling out other causes of granulomatous disorders by appropriate tests). She was managed with prednisolone 20 mg daily which was reduced and stopped after 3 months. On follow-up, she was asymptomatic and her blood counts were normal. Diagnosis of sarcoidosis should be considered always after ruling out other causes since it can mimic lymphoproliferative disorders and granulomatous infections. The initial presentation of sarcoidosis with bicytopenia due to bone marrow granulomas is extremely rare and physicians should have awareness of such atypical presentations.

P09 Uncommon cause of back pain

P09 Uncommon cause of back pain

Epitheloid granuloma of bone marrow- not always tuberculosis, think beyond what you see

Extra pulmonary tuberculosis has varied presentations and hence fever of unknown origin, with malaise, weight loss and cytopenias is generally attributed to tuberculosis in endemic regions. Tuberculosis being the most frequent cause of bone marrow granulomas, there is a risk of labelling granulomatous lesions as of infectious etiology when underlying etiology has an atypical presentation. Progressive painless lymphadenopathy, most commonly involving the cervical or supraclavicular area is the commonest presentation of Hodgkin’s lymphomas (HL) in 80%. Primary extra nodal presentation of HL is rare. We describe a case of an adolescent girl who presented with fever of unknown origin, weight loss, malaise, hematological derangements and bone marrow showing granuloma, all features pointing towards an infectious etiology, but later proven to be a case of HL.

Bone Marrow Granuloma with Miliary Mottling presenting as Pancytopenia- A rare finding in Tuberculosis - A Case report

Bone marrow granuloma and miliary mottling presenting as pancytopenia together is a rare finding in disseminated form of tuberculosis. Here we report a case of a 52-year, old male patient presented with generalized weakness, loss of appetite, decreased physical activity for one month. Initial lab hematological investigations revealed pancytopenia and high Erythrocyte sedimentation rate. Bone marrow biopsy was performed to determine the cause of pancytopenia which showed caseating granulomas with positive acid fast bacilli on Ziehl-Neelsen staining (Z-N). In chest X-ray miliary mottling and bone marrow biopsy findings together confirmed the case of disseminated tuberculosis. This unusual presentation highlights the considerable diagnostic challenge and importance of bone marrow biopsy for early diagnosis and initiation of treatment.
 Mediscope Vol. 8, No. 1: January 2021, Page 63-66

Concurrent diagnosis of oropharynx cancer and bone sarcoidosis mimicking metastasis

Bone location is uncommon in both sarcoidosis and in neck cancer (HNC). Diagnosis of a bone lesion is therefore challenging to distinguish its nature in a patient suffering from both diseases. We report the case of a 69-years-old woman referred for P16 positive HPV-HNC. Magnetic Resonance Imaging (MRI) showed T2 hypo-signal on iliac crest and spine. 18FDG-PET demonstrated radiotracer uptake on these locations suggesting bone metastasis. However, bone biopsy showed epithelioid granuloma without malignant cells compatible with sarcoidosis location. The diagnosis of both localized advanced HPV-HNC and systemic sarcoidosis (bone, central nervous system) were retained. The patient received corticosteroid regimen at 0.5mg/kg/day and Methotrexate for sarcoidosis and radiation and chemotherapy with platins for carcinoma. As granulomatous bone marrow infiltration may have an uptake on 18FDG-PET, bone sarcoidosis can mimic metastatic disease. In addition, MRI often fails to distinguish sarcoidosis lesions from metastatic lesion in bones. As no reliable imaging test can decipher both diseases, the description of our case reinforces the necessity to perform bone biopsy in a patient suffering from both conditions to expertise the nature of bone lesions.

Haematological profiles after Intensive phase of Anti Koch Treatment with special emphasis on bone marrow changes

BackgroundTuberculosis remains a major public health problem in various parts of the world. It leads to various haematological changes. Study of these haematological changes will help better patient management. Objective & methodsIt is to evaluate haematological changes in tuberculosis patients and compare the result with special emphasis to bone marrow changes as active case search is sharply decreasing the miliary tuberculosis. It is also to evaluate the patients with before and after the Intensive Phase of Anti Koch Treatment. Sputum positive and sputum negative tuberculosis patients confirmed by other ancillary techniques were included into this study. It is conducted at a tertiary level hospital in rural area. ResultIn this study bone marrow hypercellularity was of erythroid series with only 1.92% patients showed granuloma in bone marrow aspiration. In addition to bone marrow changes, significant changes were evident in haemoglobin level, Erythrocyte Sedimentation Rate (ESR) Total White Blood Cell count and RBC count. DiscussionIn majority cases this study showed Erythroid Hyperplasia. It is sharp contrast with other study where myeloid hyperplasia was evident. This study also differs from other study where high number of bone marrow granuloma was reported. In this study only 1.92% cases showed bone marrow granuloma. This study also documented higher number of anaemic cases mostly because of the institute serves poor and tribal population. ConclusionIn our study the cases showing granuloma and hyperplasia of myeloid series were limited. With introduction of Directly Observed Treatment and house to house active case search helped to sharply decrease bone marrow granuloma by limiting multi-organ spread. This study showed, ESR level may be considered as prognostic parameters of tuberculosis.

Expanding Clinical Phenotype and Novel Insights into the Pathogenesis of ICOS Deficiency

BackgroundInducible T cell co-stimulator (ICOS) deficiency has been categorized as a combined immunodeficiency often complicated by enteropathies, autoimmunity, lymphoproliferation, and malignancy. We report seven new patients and four novel ICOS mutations resulting in a common variable immunodeficiency (CVID)–like phenotype and show that dysregulated IL-12 release, reduced cytotoxic T lymphocyte–associated protein 4 (CTLA4) expression, and skewing towards a Th1-dominant phenotype are all associated with inflammatory complications in this condition.MethodsA combination of whole exome and Sanger sequencing was used to identify novel mutations. Standard clinical and immunological evaluation was performed. FACS and ELISA-based assays were used to study cytokine responses and ICOS/ICOSL/CTLA4 expression following stimulation of whole blood and PBMCs with multiple TLR ligands, anti-CD3, and PHA.ResultsFour novel ICOS mutations included homozygous c.323_332del, homozygous c.451C>G, and compound heterozygous c.58+1G>A/c.356T>C. The predominant clinical phenotype was that of antibody deficiency associated with inflammatory complications in 4/7 patients. Six out of seven patients were treated with immunoglobulin replacement and one patient died from salmonella sepsis. All patients who were tested showed reduced IL-10 and IL-17 cytokine responses, normal IL-1β, IL6, and TNF release following LPS stimulation and highly elevated IL-12 production in response to combined LPS/IFNγ stimulation. This was associated with skewing of CD4+ T cells towards Th1 phenotype and increased expression of ICOSL on monocytes. Lastly, reduced CTLA4 expression was found in 2 patients. One patient treated with ustekinumab for pancytopenia due to granulomatous bone marrow infiltration failed to respond to this targeted therapy.ConclusionsICOS deficiency is associated with defective T cell activation, with simultaneously enhanced stimulation of monocytes. The latter is likely to result from a lack of ICOS/ICOSL interaction which might be necessary to provide negative feedback which limits monocytes activation.

INCIDENTAL TUBERCULOID GRANULOMA IN BONE MARROW BIOPSY IN 17-YEAR-OLD MALE PATIENT: A CASE REPORT

Granulomas are susceptible to infrequent finding in bone marrow biopsies and may be associated with a broad spectrum of infectious and non-infectious disorders. The incidence of bone marrow granulomas is reported in 0.3% to 3% of bone marrow biopsies with tuberculoid granulomas constituting 6% to 48% of cases. Here, we report the case of a 17-year-old boy with a history of fever (pyrexia of unknown origin). There was no organomegaly and lymphadenopathy with incidental tuberculoid granuloma on bone marrow biopsy.

Amiodarone-Induced Thrombocytopenia: A Case Report

Case Presentation: An 89-year-old woman with a history of atrial fibrillation, coronary artery disease, hypertension, and recent hospitalization for intraparenchymal and intraventricular hemorrhage presented with new-onset critical thrombocytopenia secondary to amiodarone, which had started approximately 1.5 months prior to presentation. Discussion: The patient’s treatment with amiodarone was stopped on the first day of admission, at which time her platelet count was 8x109/L. She received transfusions of 4 units of platelets during her hospital stay, and her platelet count was 41x109/L at discharge. It increased to 71x109/L at follow-up with outpatient hematology 15 days after presentation and was within normal limits 7 months after hospitalization. There are 2 published reports detailing 5 separate cases of amiodarone-induced immune thrombocytopenia, and at least 8 reports of amiodarone-induced bone marrow granulomas resulting in pancytopenia. Because the patient did not have pancytopenia consistent with myelosuppression, her presentation was not reflective of bone marrow granulomas or a direct, nonimmune-mediated insult. However, the return of her platelet count to a normal level was delayed compared with the timeline presented in previous cases of both amiodarone and non-amiodarone immune-mediated thrombocytopenias. This delay in return to normal platelet count was likely secondary to the patient’s older age in the context of amiodarone’s lipophilic nature and very long half-life. Conclusion: Although a rare complication of amiodarone use, thrombocytopenia should be considered by physicians who prescribe this drug. Signs of thrombocytopenia in the context of newly prescribed amiodarone should prompt a complete blood count, discontinuation of the drug, and monitoring for resolution. If the platelet count recovers and amiodarone is found to be responsible, the medication should not be restarted, and amiodarone should be considered a drug allergy.

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.

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.

Clinicopathologic Study of Granulomatous Lesions in the Bone Marrow

Introduction: Granulomatous lesion in the bone marrowis not a common finding and can be attributed to a variety of conditions ranging from infections to malignancies to drugs. Though tuberculosis is the most common etiology, bone marrow granulomas can be associated with a number of infections and other non infective conditions. The incidence of bone marrow granulomas has been increasing over the years due to the increasing surge of HIV infection. Aims: This study basically aims to study the prevalence of bone marrow granulomas, to identify the various causes and to study the pattern of granulomas in different conditions. Materials & Methods: This is a retrospective analysis of 100 cases of bone marrow granulomas conducted in the Clinical Laboratory of Kasturba hospital for a period of four and a half years from January 2009 to May 2013.The clinical details were collected from medical records and bone marrow biopsy slides were retrieved and studied. Results: Out of the 100 cases, 66% cases were diagnosed as tuberculosis. 17% cases were due to other infections like Typhoid fever (5%), Brucellosis (4%), Scrub typhus (2%), Hansen’s disease (1%), Cryptococcosis (2%) and HIV infection itself without any other opportunistic infections (3%). Malignancies accounted for 9% cases, Sarcoidosis (1%) and in 7% cases a definitive diagnosis was not reached. Among the 66 cases of tuberculosis, 40 (60%) cases were immunodeficient due to HIV infection. HIV positive cases predominantly showed single (52%), ill defined granulomas (73%), with caseation necrosis (52%), while HIV negative cases predominantly showed single (54%), small (50%), well defined or ill defined granulomas with plump epithelioid cells (58%) and Langhans giant cells (42%). Conclusion: There can be varied etiology for bone marrow granulomas with tuberculosis being the most common cause.The morphology and pattern of granulomas can aid in the diagnosis of the condition hence study of bone marrow for granulomas should be considered as an important diagnostic tool in such conditions.

Clinical and pathological feature of bone marrow granulomas: A modern Australian series.

Marrow granulomas have been commonly associated with mycobacterial infections, prompting extensive investigations in some cases where they are found, but in the setting of changing infectious epidemiology, there is a lack of recent data to guide the search for probable causes. A retrospective case series examining the clinical and pathological findings in all cases where marrow granulomas were reported over a 10-year period at The Canberra Hospital, Australia. Of the 6062 marrow biopsies performed, 73 (1.2%) from 66 individuals had confirmed granulomas. Some patients had multiple potential causes found. B-cell non-Hodgkin Lymphoma, sarcoidosis and autoimmune disease were the most frequently observed causes. Infections were less common in this cohort than in the previous series, with no tuberculosis seen. The presence of granulomas in the marrow did not signify the presence of active malignancy in the marrow. There were no associations with any specific morphological characteristics of the granulomas and the presumed causes. Marrow granulomas are seen in a variety conditions. Neither their presence nor their morphological features are a guide to further investigations, which should be determined by the clinical presentation as appropriate.

Bone marrow granuloma due to toxoplasmosis presenting as isolated thrombocytopenia in an immunocompetent patient

Bone marrow granuloma due to toxoplasmosis presenting as isolated thrombocytopenia in an immunocompetent patient

Clinicopathological profile of salmonella typhi and paratyphi infections presenting as Fever of unknown origin in a tropical country.

BackgroundEnteric fever, a common infection in the tropics and endemic to India, often manifests as an acute febrile illness. However, presentation as fever of unknown origin (FUO) is not uncommon in tropical countries.MethodsWe aim to describe the clinical, laboratory and pathological features of patients hospitalized with fever of unknown origin and diagnosed as enteric fever. All culture proven cases of enteric fever were analyzed retrospectively over a period of three years from January 2011 to December 2013.ResultsSeven of 88 (8%) cases with enteric fever presented as FUO. Abdominal pain was the most common symptom besides fever. Relative bradycardia and splenomegaly were uncommon. Thrombocytopenia was the most common haematological abnormality while leucopenia was rare. Transaminase elevation was almost universal. S. Typhi and S. Paratyphi A were isolated from six cases and one case respectively. Yield of organisms from blood culture was superior to that of bone marrow aspirate. Multiple granulomas were identified in 4 out of 6 (67%) of the bone marrows studied, including that due to S. Paratyphi A and histiocytic hemophagocytosis was noted in two cases.ConclusionFUO is a relatively common manifestation of enteric fever in the tropics. Clinical and laboratory features may be atypical in such cases, including absence of relative bradycardia, leucopenia, and presence of thrombocytopenia, bicytopenia or pancytopenia. In addition, in endemic countries, enteric fever should be considered as a differential diagnosis, next to tuberculosis, in the evaluation of bone marrow granulomas in cases with FUO and culture correlation should be mandatory.

Childhood sarcoidosis: Louisiana experience.

A retrospective chart review was conducted to detect patients with sarcoidosis seen by pediatric rheumatology service from the period of 1992 to 2013 at Children's hospital of New Orleans. Twenty-seven patients were identified. The average duration of symptoms before diagnosis was 5 (range 1-120) months. Five patients had onset before the age of 5years and were diagnosed with early-onset sarcoidosis. The most common manifestations at presentation were constitutional symptoms (62%) followed by ocular (38%). During the course of illness, 19/27 (70%) had multiorgan involvement. Common manifestations included uveitis/iritis (77%), fever (50%), hilar adenopathy (42%), arthritis (31%), peripheral lympadenopathy (31%), hepatosplenomegaly (31%), parenchymal lung disease (27%), and skin rash (19%). Unusual manifestations included granulomatous bone marrow disease (3 cases), hypertension (2), abdominal aortic aneurysm (large vessel vasculitis; 1), granulomatous hepatitis (1), nephrocalcinosis (1), membranous nephropathy (1), refractory granulomatous interstitial nephritis with recurrence in transplanted kidney (1), CNS involvement (2), parotid gland enlargement (1), and sensorineural hearing loss (1). Biopsy specimen was obtained in 21/27 (77%) patients, and demonstration of noncaseating granuloma associated with negative stains for mycobacteria and fungi was seen in 18 patients. Elevated angiotensin-converting enzyme level was seen in 74% of patients. Treatment with oral prednisone was initiated in symptomatic patients with significant clinical improvement. Low-dose methotrexate (MTX) 10-15mg/m(2)/week orally, as steroid-sparing agent, was administered in 14 patients. Other immunomodulators included cyclophosphamide (2 patients), etanercept (2), infliximab (2), mycophenolate mofetil (1), and tacrolimus (1). Childhood sarcoidosis is prevalent in Louisiana. Most of the affected children present with a multisystem disease associated with manifestations similar to those of adult patients. Low-dose MTX seems to be effective, steroid sparing, and safe adjunct to treat sarcoidosis with multiorgan involvement. Early-onset disease is less common and associated with increased morbidity, flares, and poor prognosis.

Bone marrow granuloma in typhoid Fever: a morphological approach and literature review.

Typhoid fever is one of the few bacterial infections in humans where bone marrow evaluation is routinely recommended. However, the morphological aspect of typhoid fever in bone marrow has been rarely described in the literature. We describe a 25-year-old male patient who presented with prolonged fever suspected to be of tubercular etiology. Bone marrow examination showed well-formed histiocytic and epithelioid granulomas and erythrophagocytosis; and the bone marrow aspirate culture grew Salmonella typhi A. In view of potential clinical implications, typhoid fever should be considered as a differential diagnosis to tuberculosis in the evaluation of prolonged fever; especially in high prevalent areas. We suggest that erythrophagocytosis may serve as a morphological marker in typhoid granulomas in the bone marrow; and bone marrow culture should be submitted in every suspected case for appropriate patient management.