A 50-year-old Iraqi man presented with splenomegaly and pyrexia of unknown origin. A bone marrow aspirate was done as part of the investigations and unexpectedly showed Plasmodium falciparum parasites. Malaria had not been suspected as this condition is now rare in Iraq but it subsequently transpired that the patient had recently visited Pakistan.The gametocytes that are observed in the bone marrow differ from those that are observed in the blood, being less mature [1]. The immature gametocytes that are seen include some that are sail-shaped, spindle-shaped or oval (top) rather than the crescent-shaped macrogametocyte and sausage-shaped microgametocyte that are usually observed in the blood. This reflects the fact that gametocytes develop in the internal organs, including the bone marrow, rather than in the circulating blood. Photographs of the bone marrow of this patient show sail-shaped (left), spindle-shaped (centre) and oval (right) immature gametocytes. Some mature gametocytes were also present.
An 8-year-old Iraqi male presented with fever and pallor of 2-months duration. There was no lymphadenopathy, splenomegaly or hepatomegaly. A full blood count showed: hemoglobin concentration 6.9 g/dl, white blood cell count 1.5 3 10 9 /l and platelet count 217 3 10 9 /l. Examination of a bone marrow aspirate showed acute myeloid leukemia (AML) with little maturation; blast cells were 85% of nucleated cells, and the case was classified as FAB (French-American-British) M1 AML. An unusual feature was the presence not only of Auer rods (left) but also of pseudo-Ché diak-Higashi inclusions, which on a Romanowsky stain varied from pink to deep purple (right). In addition to typical thin Auer rods there were also thick rodshaped inclusions (left and right).Pseudo-Ché diak-Higashi inclusions are observed occasionally in AML 1 (including acute promyelocytic leukemia) and also, rarely, in refractory anaemia with excess of blasts. 2 The inclusions are formed by fusion of azurophilic (primary) granules and show myeloperoxidase activity and Sudan black B staining. On ultrastructural examination they are heterogeneous and, in contrast to the inclusions seen in the inherited anomaly, contain rod-shaped structures showing periodicity. 1 The diagnostic significance of these inclusions is likely to be similar to that of Auer rods, indicating either AML or a high grade myelodysplastic syndrome.
This composite photograph is of the peripheral blood of a 16-year-old Iraqi girl presenting with mild hepatosplenomegaly, generalized bruising and rectal bleeding. A blood count showed a white cell count of 17 3 10 9 /l, hemoglobin concentration 2.5 g/dl and platelet count 7 3 10 9 /l. A peripheral blood film made without delay showed blast cells of unusual morphology, many having striking nuclear lobulation (top); nucleoli were prominent. Some blast cells contained Auer rods or granules, confirmed on Sudan black B staining (bottom left and bottom right). Maturing myeloid cells were dysplastic. A diagnosis of acute myeloid leukemia with differentiation was made, FAB (French-American-British) M2 AML.Lobulated promonocytes are characteristic of acute monocytic leukemia and lobulated promyelocytes are similarly typical of the variant microgranular form of acute promyelocytic leukemia. However pronounced symmetrical nuclear lobulation of myeloblasts, as shown in this patient, is a quite uncommon feature of AML.
An 18-year-old Iraqi girl presented with fever and a generalized rash. The spleen was palpable four cm below the left costal margin. A full blood count showed: white cell count 3 3 10 9 /l, hemoglobin concentration 97 g/l, platelet count 63 3 10 9 /l, neutrophil count 2.2 3 10 9 /l and lymphocyte count 0.6 3 10 9 /l. A bone marrow aspirate performed to investigate the thrombocytopenia showed a normocellular marrow with normal numbers of megakaryocytes. In addition numerous LE cells were detected (left image). The LE cells were detected in bone marrow films spread immediately without any anticoagulation, incubation or other manipulation. The diagnosis of systemic lupus erythematosus (SLE) was confirmed by the demonstration of antinuclear antibody and anti-double stranded DNA antibody.An LE cell is a neutrophil that has ingested denatured nuclear material of another cell as the result of antinuclear activity in the plasma. This phenomenon was first described in the bone marrow in 1948 with a Feulgen stain being used to demonstrate that the ingested material was DNA [1]. In the subsequent year an in vitro test was reported using either buffy coat cells or normal bone marrow components plus the patient's plasma [2]. Hargraves and colleagues [1] also described the phenomenon shown in the right image -''numerous mature polymorphonuclear leukocytes attempting to pick up the same mass of material''. With the availability of serological tests an LE cell preparation is now rarely used for the diagnosis of SLE. However the observation of LE cells in a bone marrow aspirate can still provide confirmation of this diagnosis.
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