Ascites in agnogenic myeloid metaplasia: association with peritoneal implant of myeloid tissue and therapy

Peritoneal carcinomatosis-like implants of extramedullary hematopoiesis. An insolite occurrence during splenectomy for myelofibrosis

INTRODUCTION

Primary myelofibrosis (MF) is a myeloproliferative neoplasm that results in debilitating constitutional symptoms, splenomegaly, and cytopenias. In patients with symptomatic splenomegaly, splenectomy remains a viable treatment option for MF patients with medically refractory symptomatic splenomegaly that precludes the use of ruxolitinib.

CASE PRESENTATION

We present the clinical case of a patient who was admitted to our Department to perform a splenectomy in MF as a therapeutic step prior to an allogeneic stem cell transplantation (ASCT). A laparotomic splenectomy and excision of whitish wide-spread peritoneal and omental nodulations was performed. There were no operative complications and the surgery was completed with minimal blood loss. The histopathological exam revealed an extramedullary hematopoiesis in both spleen and peritoneal nodules.

CONCLUSION

In primary myelofibrosis it must always be kept in mind the possible presence of peritoneal implants of extramedullary hematopoiesis and ascites of reactive genesis. We report a rare case of peritoneal carcinomatosis-like implants of extramedullary hematopoiesis found at splenectomy for MF.

Nontuberculous mycobacterial infection in a patient with myelofibrosis: case report and concise review

A 70-year-old patient having massive refractory ascites in the course of idiopathic myelofibrosis was diagnosed of peritoneal extramedullary hematopoiesis and developed an overwhelming nontuberculous mycobacterial infection. The case describes this unusual infection and highlights the need for additional studies to confirm the etiology of ascites in primary myelofibrosis.

Myelofibrosis, hepatic extramedullary hematopoiesis and ascites associated with vitamin D deficiency in early infancy

Primary myelofibrosis is rare in children. Many causes have been described for secondary myelofibrosis including vitamin D deficiency. Here, we describe a patient with myelofibrosis secondary to vitamin D deficiency, as diagnosed by laboratory evidence. The patient also developed resultant extramedullary hematopoiesis with secondary development of ascites as a result of myelofibrosis. These are findings rarely reported in association with vitamin D deficiency. Potential mechanisms are also discussed.

Chronic idiopathic myelofibrosis with myeloid metaplasia presenting as refractory ascites

Chronic idiopathic myelofibrosis (CIM) with myeloid metaplasia is a myeloproliferative disorder characterized by leukoerythroblastosis, tear drop erythrocytes, extra-medullary hematopoesis (EMH), and varying degree of myelofibrosis. CIM, presenting as refractory ascites secondary to peritoneal hematopoesis, is extremely rare with only six adult cases reported in literature. This is a report of a child with CIM presenting as refractory ascites as a consequence of EMH in the peritoneum. The patient was treated with intermittent hydroxyurea with favorable response over 3 weeks. The patient was thereafter lost to follow up.

Extramedullary peritoneal hematopoiesis combined with tuberculosis in a patient with primary myelofibrosis

Primary myelofibrosis (PMF) is a myeloproliferative disorder characterized by bone marrow fibrosis or dysmegakaryocytes, extramedullary hematopoiesis, and the presence of JAK2 mutations. We present a 73-year-old man with PMF that had a fulminant clinical course. Peritoneal extramedullary hematopoiesis combined with tuberculosis was found 4 months after the diagnosis. This combination of complications has not been previously reported. These events were followed by rapid leukemic transformation and the patient's death.

Idiopathic myelofibrosis with extramedullary haemopoiesis involving the urinary bladder in a Chinese lady

Extramedullary haemopoiesis (EMH) associated with idiopathic myelofibrosis most commonly involves the reticuloendothelial organs, such as the spleen and liver, although ectopic haemopoietic tissue has also been described rarely in the lymph nodes, skin, gastrointestinal tract, pleura, peritoneum, central nervous system, and genital and urinary tracts. We report on a 54-year-old Chinese lady with a long history of idiopathic myelofibrosis who presented with gross haematuria and left hydronephrosis due to EMH in the bladder trigone. Cystoscopic examination revealed a sessile necrotic papillary growth at the trigone, obstructing the left ureteric orifice. Transurethral resection of the bladder tumour was performed, and microscopic examination of the tumour chips demonstrated atypical megakaryocytes, immature granulocytes and normoblasts, confirming the presence of EMH. The residual bladder tumour responded well to low dose radiotherapy, with subsequent disappearance of haematuria and normalization of ultrasonogram findings.

Ascites and pleural effusion secondary to extramedullary hematopoiesis

Extramedullary hematopoiesis in the pleura and peritoneum is rare. It is usually asymptomatic and generally is diagnosed on post mortem examination. Herein we describe a 33-year-old woman with long-standing myelofibrosis who presented with symptomatic ascites and pleural effusion. After complete evaluation, these were found to have been caused by extramedullary hematopoietic implants to the pleura and peritoneum. The pleural effusion responded to low-dose radiotherapy.

Clinical expressions of the expansion of the bone marrow in the chronic anemias: the role of radiotherapy

PURPOSE

In the chronic anemias and particularly in the hemoglobinopathies and in the myeloproliferative disorders there is compensatory hypertrophy and expansion of the bone marrow. This results in severe rarefaction of the bone and in extramedullary hemopoiesis.

METHODS AND MATERIALS

Morbid clinical expressions of the osseous changes are spontaneous fractures and osteoarthropathy, while extramedullary hemopoiesis presenting in the form of tumor-like masses may cause pressure symptoms on adjacent organs, particularly on the spinal cord.

RESULTS AND CONCLUSION

Extramedullary hemopoiesis masses can be easily diagnosed since they present typical radiological appearance. Radiotherapy has been used for the treatment of these conditions.

Idiopathic myelofibrosis with myeloid metaplasia involving the renal pelves, ureters and bladder

Myeloid metaplasia associated with idiopathic myelofibrosis most commonly involves the reticuloendothelial organs, such as the spleen, liver and retroperitoneal lymph nodes. We report on a patient with myeloid metaplasia (extramedullary hematopoiesis) of the renal pelves, ureters and bladder. The pathogenesis, clinical characteristics, treatment and prognosis of this condition are discussed.

Whole-abdominal irradiation for the management of gastrointestinal and abdominal manifestations of agnogenic myeloid metaplasia

A patient with a long-standing history of agnogenic myeloid metaplasia developed weight loss and ascites secondary to gastric/small bowel infiltration and peritoneal implants of myeloid tissue. Moderate doses of radiation were very effective in controlling her gastrointestinal symptoms. In contrast to previous reports, clinical improvement after irradiation was a slow, gradual process, requiring 5 months for complete resolution of the patient's ascites. Hematologic suppression may be profound and careful attention to the rate of change in leukocyte and platelet counts is necessary to avoid severe toxicity.

Idiopathic myelofibrosis: historical review, diagnosis and management

Idiopathic myelofibrosis is reviewed from several aspects. The historical development of knowledge about this disorder is discussed, from early descriptions of extramedullary hematopoiesis associated with numerous etiologies, a debate over pathogenetic mechanisms, followed by newer evidence which placed this disorder with the myeloproliferative disorders. Evidence is presented showing that idiopathic myelofibrosis is an acquired clonal disorder in terms of the hematopoietic abnormalities, but that the marrow fibrosis is a result of non-clonal disordered fibrogenesis. The clinical, laboratory and pathologic features of idiopathic myelofibrosis are discussed. The features which distinguish this disorder from the other myeloproliferative disorders, particularly chronic myelogenous leukemia are emphasized. The natural history is described together with an evaluation of accepted and experimental therapy.

Primary cytodiagnosis of peritoneal extramedullary hematopoiesis

Cytologic examination of peritoneal fluid in a patient with known myelofibrosis and previous splenectomy revealed megakaryocytes along with erythroid and myeloid precursors. These findings were consistent with extramedullary hematopoietic (EMH) implants of the peritoneum. A few similar cases have been occasionally reported in the literature. This case represents an additional example of a primary diagnosis of peritoneal EMH in which therapy was based on the cytologic findings and sequential cytologic observations were made.

Ascites progressing to an abdominal mass due to extramedullary hematopoiesis in a patient with agnogenic myeloid metaplasia (AMM)

We report a patient with long-standing agnogenic myeloid metaplasia who developed ascites which progressed over 6 months to a massive solid peritoneal mass as a consequence of intraperitoneal extra-medullary hematopoiesis. The clinical and radiographic features of this unusual case are presented.