Granulomatous lesions in bone marrow: clinicopathologic findings and significance in a study of 48 cases

Disseminated Mycobacterium kansasii infection due to surgical site infection following allogeneic hematopoietic stem cell transplantation: A case report and literature review

This report details a rare case of surgical site infection (SSI) caused by Mycobacterium kansasii following allogeneic hematopoietic stem cell transplantation (allo-HSCT) in a 53-year-old patient with IgA-κ type multiple myeloma. After undergoing multiple chemotherapy regimens and two stem cell transplants, the patient developed an SSI 31-month post-transplantation, manifesting as an intracranial abscess at the site of a previous craniotomy. M. kansasii was isolated from the drainage fluid, marking this instance as a unique case in the literature of nontuberculous mycobacteria (NTM) infection post-allo-HSCT with such a delayed onset. The patient's treatment included targeted antimicrobial therapy based on susceptibility testing, resulting in eventual resolution of the infection, although the patient later succumbed to multiple myeloma relapse. This case underscores the critical need to consider NTM infections in the differential diagnosis of persistent fevers and SSIs in immunocompromised patients, particularly those with chronic graft-versus-host disease. It highlights the importance of early diagnostic and therapeutic interventions to manage these infections effectively. This report contributes to the limited but growing body of literature on NTM infections post-allo-HSCT and emphasizes the need for vigilance in monitoring postoperative patients, especially those with prolonged immunosuppression.

Hematologic and Oncologic Aspects of Sarcoidosis: Some of the Least Studied but Most Common Dilemmas

The hematologic system is frequently involved in sarcoidosis. Lymphopenia is the most common hematologic manifestation noted, although anemia and thrombocytopenia also occur. The etiology of these common manifestations can be direct granulomatous infiltration of bone marrow, lymph nodes, or spleen or related to immunologic dysfunction. Although not life threatening, these problems can lead to cytopenias requiring close monitoring in patients receiving a variety of disease treatments. The relationship between sarcoidosis and malignancy remains complex. However, some sarcoidosis patients are at increased risk for the development of malignancies, particularly lymphomas and gastrointestinal cancers. Conversely, cancer patients can experience an increase in the likelihood for the development of breast cancer and lymphomas.

Granulomas in bone marrow biopsies: clinicopathological significance and new perspectives

Bone marrow granulomas in trephine biopsies are a rare and usually incidental finding. Possible causes include infectious (especially tuberculous and rarer non-tuberculous mycobacteria, but also many other bacterial, viral, fungal and parasitic agents) and non-infectious causes (especially medications, autoimmune disease, sarcoidosis, haematological and non-haematological malignancy). Necrotising granulomas are generally suggestive of an infectious aetiology (tuberculosis being the most common), whereas fibrin ring granulomas are associated with Q-fever and Epstein Barr Virus, although exceptions are possible. Every case suspicious for infectious aetiology should undergo further analysis like special staining (Ziehl-Neelsen for acid-fast rods) or molecular studies. The histomorphology should always be clinically correlated. In cases in which no infectious cause can be identified, untargeted metagenomics may represent a valid diagnostic tool that may become standard in the near future for bone marrow diagnostics. In this review, we have analysed the published data from 1956 up to today, and we report aspects of epidemiology, aetiology, diagnostic algorithms, differential diagnosis and the role of metagenomics in bone marrow biopsies with granulomas.

Bone Lipogranuloma Mimicking Metastatic Disease on 18F-FDG PET/CT

ABSTRACT

Primary bone lipogranuloma is an extremely rare disease associated with reactive inflammatory granulomatous reaction associated with exogenous or endogenous lipids. Herein, we report a case of bone lipogranuloma with intense 18F-FDG uptake, which mimics metastatic disease on 18F-FDG PET/CT in a patient with breast cancer.

Isolated bone marrow sarcoidosis presenting as fever of unknown origin in a case of chronic myeloid leukemia

Background

Isolated involvement of bone marrow in sarcoidosis has not been reported commonly. Sarcoidosis is a systemic granulomatous disease of unknown origin, characterized by the presence of non-caseating granulomatous lesions. There should be high index of suspicion in patients having underlying lymphoproliferative malignancies.

Case presentation

We present a 27-year-old male, known case of chronic myeloid leukemia, presenting as fever of unknown origin diagnosed with isolated bone marrow sarcoidosis.

Clinical Features, Histopathology and Differential Diagnosis of Sarcoidosis

Sarcoidosis is a chameleon disease of unknown etiology, characterized by the growth of non-necrotizing and non-caseating granulomas and manifesting with clinical pictures that vary on the basis of the organs that are mainly affected. Lungs and intrathoracic lymph nodes are the sites that are most often involved, but virtually no organ is spared from this disease. Histopathology is distinctive but not pathognomonic, since the findings can be found also in other granulomatous disorders. The knowledge of these findings is important because it could be helpful to differentiate sarcoidosis from the other granulomatous-related diseases. This review aims at illustrating the main clinical and histopathological findings that could help clinicians in their routine clinical practice.

Sarcoidosis with Rare Extrapulmonary Involvement

Sarcoidosis is a systemic granulomatous disease in which medullary involvement is a rare extrapulmonary manifestation. We present the case of a 37-year-old man with right abdominal and dorso-lumbar pain lasting for months. Computerized tomography showed renal microlithiasis and retroperitoneal, hilar and mediastinal adenopathies. Laboratory results showed an elevated erythrocyte sedimentation rate, IgG, β2-microgobulin and angiotensin-conversion enzyme, serum calcium in the upper limit and hypercalciuria. There was a slight elevation of the CD4/CD8 ratio in bronchoalveolar lavage, without lymphocytic alveolitis. An endobronchial ganglion biopsy was inconclusive. A positron emission tomography scan demonstrated supra and infra-diaphragmatic, splenic and medullary involvement, suggesting lymphoproliferative disease (LPD). A bone marrow biopsy (BMB) revealed sarcoid-like epithelioid cell granulomas, excluding LPD. Sarcoidosis was assumed and corticosteroids were started. Although cytopenias were not present, the extensive ganglion, splenic and medullary involvement made LPD exclusion imperative, while BMB allowed for a definitive diagnosis.

LEARNING POINTS

Sarcoidosis is a multisystemic granulomatous disease in which medullary involvement is a rare extrapulmonary manifestation.Bone marrow biopsy is rarely performed based on serial blood counts, which may be associated with underdiagnosis.FDG-PET cannot reliably distinguish between sarcoidosis and lymphoproliferative disease as the cause of extensive ganglion, splenic and bone marrow involvement, and so a high index of clinical suspicion is required.

HIV-associated Hodgkin Lymphoma with a Granulomatous Bone Marrow Biopsy: A Case Report

The incidence of HIV-associated Hodgkin lymphoma has risen during the era of combined antiretroviral therapy (ART) despite the proven, protective effects of ART as treatment for HIV. The clinical presentation of Hodgkin Lymphoma may also resemble disseminated mycobacterial infection - in symptoms, laboratory findings, and even bone marrow biopsy. This is a case report of a patient with HIV who was suspected to have disseminated mycobacterial infection after a first bone marrow biopsy showed granulomatous inflammation and was later found to have HIV-associated Hodgkin lymphoma on a repeat biopsy.

Bone marrow involvement: Atypical presentation of early-onset childhood sarcoidosis

Childhood sarcoidosis is a chronic multisystemic, non-caseating granulomatous disease of unknown etiology. Early-onset disease classically presents with a triad of skin rash, uveitis, and arthritis, but bone marrow involvement is rare. We report a 9-1/2-year old Indian female child who presented with bleeding manifestation, skin rash, uveitis, and arthritis. Bone marrow biopsy showed multiple non-necrotizing granulomas comprising epithelioid cells, mature lymphocytes, and multinucleated giant cells with few eosinophils in the background, with negative staining for acid-fast bacilli or fungi. She was treated successfully with oral prednisolone. This is the first report of an early-onset childhood sarcoidosis with bone marrow involvement from India.

A case of bone marrow involvement in sarcoidosis with crescentic glomerular lesions

Renal and bone marrow involvements in sarcoidosis are rare. We experienced the case of a 67-year-old man with systemic sarcoidosis, with bone marrow involvement, hepatic involvement and a unique constellation of renal lesion with cellular crescent formation. Immunosuppressive therapy was helpful for maintaining the stability of his pancytopenia, hepatic function and renal function. To the best of our knowledge, the association between sarcoidosis, bone marrow involvement and crescentic glomerulonephritis has been reported in only few cases in literature.

Bone Marrow Sarcoidosis with Pancytopenia and Renal Failure Presenting as Fever of Unknown Origin: The Pivotal Role of 18F-FDG PET/CT in Lesion Detection

We describe a case of fever of unknown origin (FUO), renal failure, and pancytopenia. Initially, lymph proliferative disorder was suspected; therefore, bone marrow biopsy and 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) were performed. Bronchoscopy and lung biopsy were performed because of abnormal FDG uptake in both lung fields. Imaging data and laboratory and histological results confirmed sarcoidosis with bone marrow invasion. The patient was discharged after favorable response to corticosteroid therapy. Sarcoidosis may present as FUO without typical specific presentations in the skin or lungs. Combined 18F-FDP PET/CT helped identify the biopsy site and confirmed the sarcoidosis diagnosis.

CT-guided bone marrow aspirations and biopsies: retrospective study and comparison with blind procedures

PURPOSE

To compare the pathology results of CT-guided and blind bone marrow aspirations and biopsies.

METHODS

Ninety-eight consecutive CT-guided biopsies and 98 age- and gender-matched blind (non-CT-guided) posterior iliac crest bone marrow aspirations and biopsies performed in 2017 were reviewed for adequacy of core biopsies and aspirate smears. CT procedure images and CT abdomen/pelvis images were reviewed to evaluate anatomic features of the posterior ilium and soft tissues. Statistical analysis was performed using a T test, Fisher exact test, and Kruskal-Wallis test.

RESULTS

There was no significant difference in the age and gender of the two groups (p > 0.05). However, the CT-guided group had a higher BMI (p = 0.0049) and posterior soft tissue thickness (p = 0.0016). More CT-guided biopsy samples (CT 93 (95%); blind 77 (79%); p = 0.0006) and aspirate smears (CT 90 (92%); blind 78 (80%); p = 0.042) were categorized as adequate. The CT-guided group had longer core lengths (CT 1.4 ± 0.6 (range 0.3-3.5) cm; blind 1.0 ± 0.60 (range 0-2.6) cm; p = 0.0001). Overall, 131/164 (80%) of the cases had at least one of the described features (slanted posterior ilium (angle > 30°), 30%; rounded posterior ilium, 20%; thick posterior ilium cortex, 13%; focal lesion in posterior ilium, 12%; prior procedure in posterior ilium, 5%; posterior soft tissue thickness > 3 cm, 40%).

CONCLUSION

CT-guided bone marrow procedures were more likely to result in both adequate aspirate smears and biopsy samples and longer core lengths when compared with blind procedures.

Bone marrow involvement in sarcoidosis: an elusive extrapulmonary manifestation

Sarcoidosis is a granulomatous disease with various extrapulmonary manifestations. We describe a 51-year-old African American woman with a history of cutaneous sarcoidosis admitted with bicytopenia. Suspicion for systemic sarcoidosis was established after contrast-enhanced computerized tomography of the chest, abdomen and pelvis showed a pulmonary nodule, diffuse lymphadenopathy and hepatosplenomegaly. Cytopenias in sarcoidosis, when present, may reflect bone marrow infiltration. Hence, biopsy was obtained and bone marrow sarcoidosis was diagnosed. This manifestation, in spite of ethnic and gender predilection, is rarely seen. As with other forms of sarcoidosis, treatment comprises of corticosteroids.

Abbreviations: ANCA: Antineutrophil cytoplasmic antibody; BM: Bone marrow; BMS: Bone marrow sarcoidosis; CT: Computerized tomography; HIV: Human immunodeficiency virus; HLA: Human leukocyte antigen; MRI: Magnetic resonance imaging

Mycobacterium Chimaera Mimicking Sarcoidosis

Mycobacterium chimaera (M. chimaera) is a slow-growing nontuberculous mycobacteria usually associated with pulmonary infection in immunocompromised patients. Attributed to a specific brand of contaminated heater-cooler units used during cardiac surgery, M. chimaera has become a global public health concern due to disseminated infection affecting immunocompetent hosts. Given its nonspecific presenting symptoms and indolent course of infection, M. chimaera can mimic and be misdiagnosed as sarcoidosis. Increased awareness among the medical community and at-risk population should be maintained to facilitate more rapid diagnosis and prevent inappropriate treatment of this potentially devastating condition.

Bone marrow granulomas in a high tuberculosis prevalence setting: A clinicopathological study of 110 cases

Granulomas were reported in 0.3% to 3% of bone marrow biopsies. The aim of the study was to evaluate the incidence and etiology of bone marrow granulomas (BMGs) in the West China Hospital, which located at a high tuberculosis (TB) prevalence area in China.A retrospective case review was performed on 11,339 bone marrow biopsies at the West China Hospital of Sichuan University between January 2011 and December 2015. Cases with BMGs were retrieved and their clinical data and histopathological features were collected, examined, and analyzed.Out of 11,339, 110 cases showed granulomatous lesions in the bone marrow biopsies (0.97%). Etiologies were indentified in 80 cases (72.8%), with infections being the most common (64.5%), following by malignancies (4.5%) and autoimmune diseases (3.6%). Among infectious cases, 87.32% (62/71) cases were diagnosed as TB, a positive acid-fast stain or/and polymerase chain reaction (PCR) result for mycobacterium TB DNA fragment amplification was obtained for 35 cases. In 30 cases (27.27%), a definite diagnosis could not be established.In a TB high prevalence region in China, with a combined histological, clinical, serological, and molecular approach, we were able to clarify the cause in 72.73% of the bone marrow granulomatous cases. TB is the most common underlying etiologies. Therefore, acid-fast stain and quantitative PCR for mycobacterium TB DNA amplification are recommended as a routine for bone marrow biopsies in TB high prevalence regions.

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

INTRODUCTION

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Mycobacterial bone marrow infections at a medical centre in Taiwan, 2001-2009

Mycobacterial bone marrow (BM) infection is the most common diagnosis established by BM examinations for fever of unknown origin. In this study, clinical features and outcomes of patients who fulfilled the criteria for BM infection due to Mycobacterium tuberculosis (MTB) and non-tuberculous mycobacteria (NTM) at a medical centre in Taiwan from 2001 to 2009 were investigated. The BM histopathological findings were also analysed. A total of 24 patients (16 men, eight women) with mycobacterial BM infections were found. Of these, nine (38%) were positive for human immunodeficiency virus (HIV) and six (25%) had no pre-existing immunocompromised conditions. MTB isolates were obtained from 11 (46%) patients and NTM species were isolated from 10 (42%) patients, including M. avium complex (MAC, n = 7) and M. kansasii (n = 3). Patients with MTB infections were significantly older than those with NTM infections (60·5 vs. 47·7 years, P = 0·043) and were less likely to have a positive BM culture (45% vs. 100%, P = 0·012). The 90-day survival rates for MTB and NTM BM infections were 68% and 60%, respectively (P = 0·61). In addition, the presence of BM granulomas was significantly more common in patients with MTB BM infections than in those with NTM infections (82% vs. 30%, P = 0·030). In Taiwan, the importance of NTM was not inferior to MTB and besides MAC, M. kansasii might be an important pathogen in non-HIV-infected patients. The presence of BM granulomas and caseation provides valuable information regarding early treatment pending culture results.