Marrow hypoplasia in anorexia nervosa

Gelatinous transformation of bone marrow: rare or underdiagnosed?

Gelatinous transformation of the bone marrow (GTBM) is a rare hematologic entity, which was first described by Paul Michael in 1930. GTBM is mostly associated with caloric intake/anorexia nervosa, although it also has been described accompanying other pathologic conditions, such as malignancy, systemic lupus erythematosus, HIV infections. Even though the diagnostic features of the hematopoietic tissue, such as hypoplasia, adipose cell atrophy, and deposition of a gelatinous substance in the bone marrow (which stains with Alcian blue at pH 2.5) are quite specific, the underlying pathogenic mechanisms remain poorly understood. Considering the evidence of reversibility—notably in cases of malnutrition and anorexia—this entity should be kept high on cards as a possible differential diagnosis of patients presenting with cytopenias and associated weight loss or starvation, especially in developing countries with nutritionally deprived populations. On an extensive review of the literature aimed at comprehensively addressing the evolution of the GTBM from the past century until now, we conclude that the lack of clinical suspicion and awareness regarding this pathologic entity has led to misdiagnosis and delayed diagnosis.

Bone loss without the loss of bone mineral material? A new perspective on anorexia nervosa

Since the advent on non-invasive in vivo clinical bone densitometry, investigators have reported that regional bone mineral material loss accompanies the onset and continuance of anorexia nervosa (AN). Initial single-energy photon absorptiometric (SPA) studies were followed by a succession of dual-energy X-ray absorptiometric (DXA) investigations, and a few single-energy quantitative computer assisted tomographic (SEQCT) bone densitometry vertebral measurements. Although most all DXA studies found a relatively small diminution (approximately 3%) of bone mineral material at lumbar vertebral and proximal femoral bone-sites of AN-afflicted adolescent girls and young women, these findings have been consensually interpreted and near-universally accepted as losses of actual bone mineral material accompanying AN. It has also been claimed by some that about 50% of those beset by AN while still young adolescents were osteoporotic. Nonetheless, over the last intervening 2 decades of these studies, no specific underlying direct bone-biological causal link between AN and trabecular bone material loss has yet been uncovered. The present exposition shows that in vivo SPA, DXA, and SEQCT measurements of bone mineral material losses do not constitute evidence of actual loss of bone material, and that the attribution of osteopenia and osteoporosis to AN-afflicted younger adolescent girls is not sustainable. Rather, the full gamut of these reported bone material "losses" can be accounted for by the already well-documented AN-induced changes in the anthropometrics and compositional mixes of extra-osseous soft tissues (primarily in a very noticeable reduction of extra-skeletal fat) and intra-osseous bone marrow yellowing (marrow hypoplasia and marrow cell necrosis). These changes in soft tissue compositions and anthropometrics alone have been shown to be sufficient to cause in vivo SPA, DXA, and SEQCT to systematically mis-estimate true bone material density and erroneously register changes in bone mineral content, even when no actual changes in bone mineral material have occurred. As a result, it is seen that in vivo bone densitometry methodologies have not demonstrated that AN induces actual loss of bone mineral material. It is also demonstrated that DXA and SEQCT bone density measurements of predominantly trabecular bone-sites cannot be relied upon as gauges of heightened propensity for early (or late) osteoporotic development.

The hematology of anorexia nervosa

OBJECTIVE

Changes of the peripheral blood cell count in patients with anorexia nervosa (AN) are frequent. Anemia and leukopenia are observed in one-third of these patients. Examination of the bone marrow reveals in almost 50% of the patients with AN signs of bone marrow atrophy and can additionally suffer from a gelatinous bone marrow transformation.

METHOD

Published studies and investigations concerning hematological changes in patients with AN were reviewed.

RESULTS

Anemia and mild neutropenia are detectable in almost one-third of these patients, whereas thrombocytopenia is rather uncommon. The exact mechanism for these findings is still unclear, but 50% of AN-patients with hematological changes display morphological signs of partial bone marrow atrophy.

DISCUSSION

Changes of the peripheral blood cell count in patients with AN is a frequent observation but the peripheral blood cell count cannot predict the severity of bone marrow atrophy. All hematological and morphological alterations disappear completely and rapidly after sufficient refeeding.

Aplastic anemia in cats - clinicopathological features and associated disease conditions 1996-2004

A retrospective study of 128 feline bone marrow reports identified 13 cases of aplastic anemia. Clinical diagnoses included chronic renal failure (n=5), feline leukemia virus infection (n=2), hyperthyroidism treated with methimazole (n=1) and idiopathic aplastic anemia (n=5). In some cats, starvation may play a role in the development of marrow aplasia. Some cats with aplastic anemia can have prolonged survival without resolution of the pancytopenia.

[Gelatinous bone marrow transformation in anorexia nervosa]

Moderate hematologic abnormalities, like anemia or leukopenia, are frequently seen in anorexia nervosa, whereas pancytopenia and bone marrow abnormalities are uncommon. We report a case of tricytopenia with gelatinous bone marrow transformation in anorexia nervosa. Marrow gelatinous transformation (also called serous fat atrophy or starvation marrow) is characterized by the association of marrow hypoplasia and interstitial infiltration of a ground gelatinous substance (acidic mucopolysaccharides). Changes in peripheral blood cell counts are various and moderate, and do not always reflect the severity of bone marrow damage. The pathogenesis is not yet well elucidated but is certainly related to the nutritional status because gelatinous bone marrow transformation is found in anorexia nervosa and in other clinical situations with cachexia. Gelatinous transformation of the marrow is reversible with feeding.

Bone marrow changes in anorexia nervosa are correlated with the amount of weight loss and not with other clinical findings

The clinical history and biochemical and hematologic variables for 44 consecutive patients diagnosed with anorexia nervosa were recorded. Bone marrow aspirates and biopsy specimens were analyzed by standard morphologic procedures, and bone marrow adipocytes were studied morphometrically. The bone marrow of the 44 patients was classified as normal (5 cases [11%]), hypoplastic or aplastic (17 [39%]), with partial or focal gelatinous degeneration (13 [30%]), or with complete gelatinous degeneration of the bone marrow (GDBM; 9 [20%]). These patterns correlated with amount of weight loss (P = .005) but not other clinical findings. WBC counts were lower in patients with GDBM (P = .0189), but this and other peripheral blood variables did not always reflect the severity of bone marrow damage. Hypoplastic or aplastic bone marrow showed an increase in bone marrow fat fraction due to an increase in adipocyte diameters, while in GDBM, fat fraction and adipocyte diameters decreased. Morphologic changes in bone marrow and stereologic alterations in bone marrow adipocytes may be observed in anorexia nervosa. The extent of damage is related to the amount of weight loss, not to other factors. Peripheral blood cell counts may not reflect the extent of damage. In some patients, this process may be reversible with reestablishment of adequate nutritional intake.

Gelatinous transformation of bone marrow from a starch-free diet

Gelatinous marrow transformation is characterized by marrow hypoplasia, fat atrophy, and gelatinous material deposition, and usually develops as a hematologic complication of chronic wasting disorders. Most of the cases associated with severe nutritional deficiency were seen in anorexia nervosa due to a depletion of protein or fat. This report describes a case of gelatinous transformation attributed to a specific restriction of carbohydrates in diet. The hematologic deficiency was eventually recovered after the patient resumed a regular starch-containing diet. This brief report illustrates the potential side effect of the compulsive dietary behavior on the hematologic system.

Magnetic resonance spectroscopic and relaxometric determination of bone marrow changes in anorexia nervosa

OBJECTIVE

The objective of this study was to assess and quantify bone marrow changes in patients with anorexia nervosa using 1H magnetic resonance spectroscopy and relaxometry.

METHODS

The bone marrow fat fraction and the longitudinal and transverse relaxation times (T1 and T2, respectively) of water were measured in the lumbar and femoral marrow of 20 patients with anorexia nervosa and 19 healthy control subjects.

RESULTS

Patients with anorexia nervosa showed significant hyperhydration and reduction of the fat fraction in their bone marrow, predominantly in the proximal femur. These changes were associated with hematological abnormalities. In a retest of seven patients after psychotherapy and gain of weight, the pathological changes in marrow proved to be largely reversible in correlation with the increase in body mass index.

CONCLUSIONS

Fat depletion and excess of tissue water in the bone marrow in anorexia nervosa can be quantified by 1H magnetic resonance spectroscopy and relaxometry. The distribution of the pathological changes in the lumbar and femoral marrow follows the pattern of normal bone marrow conversion from hematopoietic to cellular during childhood.

Reversal of bone marrow hypoplasia in anorexia nervosa: case report

BACKGROUND

Bone marrow hypoplasia seems to be uncommon in anorexia nervosa. This marrow abnormality is rapidly reversible with intensive nutritional rehabilitation. The patient described in this case report had anorexia nervosa.

METHOD

She presented with complete serous atrophy of the bone marrow associated with pancytopenia.

RESULTS

She was cured with recombinant human erythropoietin administered subcutaneously. After 25, days, the hematological situation was normalized.

DISCUSSION

The possible advantage and practical implications of the administration of erythropoietin are discussed.

Magnetic resonance imaging of clival marrow in patients with anorexia nervosa

Hematological abnormalities, commonly associated with anorexia nervosa (AN) patients, are thought to be the results of serous atrophy in the bone marrow. Magnetic resonance imaging (MRI) has been utilized to ascertain T1 and T2 prolongation of marrow intensity in the lumbar spine, pelvis and proximal femora. The results correlate well with the severity of hematological abnormalities, and body mass index. More importantly, the propensity for peripheral marrow involvement of T2 prolongation contrasts with the axial involvement in other marrow disorders. MRI undertaken in patients with AN to exclude hypothalamic tumor showed that the clival marrow was equivalent to the peripheral marrow. The signal pattern of clival marrow on sagittal T1 weighted MR images was evaluated in four teenage female patients with AN complicated by hematological abnormalities. Although the clival marrow intensity should be uniformly high in teenagers, three patients, two with pancytopenia and one with leukopenia and anemia, exhibited homogeneous low intensity. One patient who had leukopenia only and the highest body mass index, showed inhomogeneous low intensity. The signal changes returned to normal in all patients but one, who died before examination after 6-11 months, at which time the others had almost recovered their original weight and normal hemogram. T1 prolongation in the clival marrow represents bone marrow dysfunction and the inhomogeneity of the signal change may imply relative preservation of hematopoiesis and body fat composition. Lack of knowledge of this phenomenon may lead to diagnostic confusion with other marrow disorders on cranial MRI.

Bone marrow necrosis

Bone marrow necrosis is regarded as an uncommon entity that is associated with a poor prognosis. However, organized studies using either bone marrow biopsy specimens or autopsy material showed that bone marrow necrosis can be demonstrated in approximately one third of specimens. It is found in a large number of both malignant and nonmalignant disorders, in addition to occurring following large exposures to radiation or high dose cancer chemotherapy. In the absence of radiation or cancer chemotherapy, it probably eventuates from either vascular occlusion or blood stasis in small blood vessels. When bone marrow necrosis is prolonged, it may be associated with the development of bone marrow fibrosis, and it may serve as a predisposing etiology for idiopathic myelofibrosis. Most patients discovered with bone marrow necrosis have few symptoms, and they are eventually lost to follow-up without evident progression or development of a clinical illness. In acute disorders and in those who undergo effective therapy, recovery appears to occur without complications. This frequently overlooked finding is the subject of many case reports in the medical literature, but it has only been rarely systematically investigated. The latter is probably warranted because of the potential role of bone marrow necrosis in the pathophysiology of a number of disorders and the paucity of information for treatment of this pathological finding.

Bone marrow hypoplasia in anorexia nervosa: a case report

If hematological abnormalities appear to be a common feature of severe anorexia nervosa, on the other hand bone marrow hypoplasia seems to be comparatively rare. We recently encountered a patient with anorexia nervosa who demonstrated a hypoplastic bone marrow associated with gelatinous transformation. These abnormalities were rapidly reversible with intensive nutritional rehabilitation. Bone marrow hypoplasia and gelatinous transformation are discussed in relation to current concepts of the role of nutrition in hematopoiesis in humans.

Differentiation of primitive human multipotent hematopoietic progenitors into single lineage clonogenic progenitors is accompanied by alterations in their interaction with fibronectin

We have previously demonstrated that primitive progenitors from human bone marrow termed long term bone marrow culture initiating cells (LTBMC-IC) adhere avidly to irradiated bone marrow stroma, while more mature clonogenic progenitors fail to do so. In this study we examine the interaction between these progenitors and components of the bone marrow stroma. (a) We demonstrate that both primitive LTBMC-IC and more mature clonogenic progenitors adhere to intact fibronectin. (b) Primitive LTBMC-IC and multi-lineage CFU-MIX progenitors adhere to the 33/66 kD COOH-terminal heparin-binding cell-adhesion promoting fragment of fibronectin, but adhere significantly less to its 75 kD RGDS-dependent cell-binding fragment. In contrast, more differentiated single-lineage progenitors adhere equally well to the 33/66 kD RGDS independent and the 75 kD RGDS-dependent cell-adhesion fragments of fibronectin. (c) Both primitive LTBMC-IC and clonogenic progenitors adhere to the three known cell-attachment sites in the 33/66 kD cell-adhesion promoting fragment, FN-C/H I, FN-C/H II and CS1. However, LTBMC-IC and CFU-MIX progenitors adhere significantly better to FN-C/H II than to the flanking FN-C/H I and CS1 cell-attachment sites. In contrast, single-lineage progenitors adhere equally well to all three cell attachment sites in the 33/66 kD cell-adhesion promoting fragment. (d) Finally, adhesion of primitive LTBMC-IC to intact irradiated stroma can be inhibited partially by peptide FN-C/H II and almost completely by a combination of FN-C/H II and peptide FN-C/H I and CS1. This study demonstrates that adhesive interactions between primitive hematopoietic progenitors and the extracellular matrix component fibronectin can occur. Specific changes in adhesion to the 33/66 kD cell-adhesion promoting fragment and the 75 kD RGDS-dependent cell-adhesion fragment of fibronectin are associated with differentiation of primitive multi-lineage progenitors into committed single-lineage progenitors. Such differences in adhesive interaction with fibronectin may allow hematopoietic progenitors at various stages of differentiation to interact with specific supportive loci of the bone marrow microenvironment. Finally, the ability to block adhesion of LTBMC-IC to intact irradiated stroma with peptides FN-C/H II, FN-C/H I and CS1 suggests that receptors responsible for this interaction may be important in the homing of primitive progenitors to the bone marrow.

Medical complications of anorexia nervosa and bulimia nervosa

The internist plays a critical role in the care of eating disorder patients, especially in the management of the life-threatening medical complications of these conditions. In anorexia nervosa, the immediate danger is related to the effects of voluntary starvation, including hypophosphatemia, bone marrow failure, cardiac decompensation, and shock. Patients with bulimia nervosa more often experience severe fluid and electrolyte abnormalities resulting in hypovolemia, secondary hyperaldosteronism, depletion of total body potassium, and cardiac arrhythmias. Immediate management of medical complication and correction of nutritional deficits are necessary before patients can benefit from psychotherapy. The need for continued involvement of the internist in the ongoing care of the eating disorder patient is stressed. The high mortality and the likelihood of chronicity without early intervention underscore the need for early recognition and skilled management of eating disorders.

Reversal of severe serous atrophy of the bone marrow in anorexia nervosa

The patient described in this case report had anorexia nervosa, which ultimately was fatal. She presented with complete serous atrophy of the bone marrow associated with pancytopenia. After 2 weeks of intensive nutritional support, her peripheral blood counts had returned to normal. At autopsy on day 24, the serous atrophy had resolved and the bone marrow was populated by normal numbers of hematopoietic precursors. This case is unique in demonstrating that starvation-induced severe serous atrophy of the bone marrow is reversible with nutritional intervention.

Marrow cell necrosis in anorexia nervosa and involuntary starvation

Marrow specimens from six patients with anorexia nervosa and three with involuntary starvation were examined for the presence of gelatinous transformation and marrow cell necrosis. Five of the patients had pancytopenia. Acanthocytes were present in the circulation of all nine. In only two patients was marrow cellularity adequate. Gelatinous transformation was present in every marrow specimen and was of a marked degree in eight. Marrow cell necrosis was identified in all nine marrow specimens. The necrosis was extensive in one specimen, focal in the others and limited to the areas of gelatinous transformation. Severe malnutrition was the single element common to all the patients.

Hematologic abnormalities simulating anorexia nervosa in an obligatory athlete

Obligatory runners and patients with anorexia nervosa share psychologic characteristics. The intensely atheletic person described in this report demonstrated hematologic abnormalities identical to those previously reported in anorexia nervosa. These findings, as well as nonhematologic features of the case, support the contention that obligatory running and anorexia nervosa represent interrelated disorders.

Prepubertal periodontitis affecting the deciduous and permanent dentition in a patient with cyclic neutropenia. A case report and discussion

Neutropenia is a transient or chronic blood disorder characterized by a decrease in the number of circulating polymorphonuclear leukocytes (PMNs). Neutrophils are a major cellular defense against infection, and depletion of these cells is potentially fatal. Stomatitis and gingivitis frequently are seen in patients with neutropenia. Therefore, the diagnosis of severe oral pathoses of obscure origin must include a differential white blood cell count. The importance of the dentist's role is dramatically illustrated in the rare case reported here, since the oral condition was the reason for this patient's definitive blood work-up. The report illustrates the importance of the laboratory assessment in dental patients with unusual periodontal destruction or other inexplicable oral changes.

Gelatinous transformation of the bone marrow

A case of gross macroscopic gelatinous transformation of bone marrow associated with prolonged malabsorption due to celiac disease is reported. Histochemical studies support the view that the extracellular myxoid tissue is composed predominantly of acid mucopolysaccharides, and electron microscopy shows extracellular fine fibrillar and granular material. The replacement of marrow in this condition is histochemically different from serous fat atrophy occurring in epicardial fat, and it is suggested that it results from an increase in normal ground substance. It must be differentiated from metastatic signet ring adenocarcinoma.

Bone marrow necrosis

Bone marrow necrosis has been regarded as a rare entity in specimens obtained from living patients and has been associated with poor prognosis. In contrast, we believe that it is a commonplace finding in bone marrow specimens which is frequently overlooked and which occurs in patients with multiple acute and chronic disorders. It is postulated that bone marrow necrosis eventuates from vascular occlusion of small blood vessels as a result of a number of causes. When bone marrow necrosis is prolonged, it may be associated with the development of bone marrow fibrosis and serve as a predisposing lesion for idiopathic myelofibrosis. Additional investigation of this phenomenon is required to determine its usefulness in the diagnosis of disease states and its role in the pathophysiology of a number of disorders.

Gelatinous transformation of the bone marrow

A study of so-called gelatinous transformation of the bone marrow in 14 patients is presented. The condition is characterized by the presence of extracellular "gelatinous" material, fat atrophy, and associated focal marrow hypoplasia and is often mistaken as representing edema, necrosis, or amyloid. Histochemical studies indicate that the extracellular substance is hyaluronic acid. Though the lesion is usually associated with severe weight loss and cachexia, it appears that factors other than malnutrition must play a significant role in the pathogenesis of gelatinous transformation. Anemia, frequently seen in these patients, does not appear to be a consequence of gelatinous transformation.

[Haematological features of anorexia nervosa (author's transl)]

Nine patients with anorexia nervosa were studied, who had varying degrees of bone marrow failure ranging from a slight neutropenia to severe pancytopenia. In addition to routine laboratory work bone marrow biopsies were performed at admission and during the course of disease. In four of those patients erythropoietin excretion per 24 hours was measured by the bioassay in the polycythemic mouse at least twice during the course of treatment. At admission most bone marrow showed a marked although varying hypocellularity with grossly apparant background gelatinous material, which appeared to consist of acid mucopolysaccharides. Leukopenia and the changes of the bone marrow morphology reversed to normal after refeeding. Erythropoietin excretion was only elevated in patients who were anemic and returned to normal when the haematocrit reached normal levels. It seems therefore unlikely that an impaired production of erythropoietin or other postulated humoral factors cause the haemopoietic changes in anorexia nervosa. A direct effect of fat or carbohydrate depletion and/or of the increased mucopolysaccharides upon the proliferation of the haemopoietic cells can be suggested, but is an entirely speculative preposition.

A histochemical study of bone marrow hypoplasia in anorexia nervosa

The bone marrow in patients with anorexia nervosa is commonly hypoplastic with transformation of marrow fat. The normal fat cells which appear clear and open in the marrow are surrounded by an amorphous, gelatinous material, thought to represent an increase in the ordinary acid mucopolysaccharide ground substance of the bone marrow. Since this lesion has a similar appearance grossly and microscopically to the lesion of serous fat atrophy found in cachectic patients, we have compared the histochemical properties of this amorphous material in a bone marrow from a patient with anorexia nervosa and from cachectic patients with epicardial serous fat atrophy and with the background substance in hypoplastic marrows. Both this fat-associated deposition in the bone marrow and serous fat atrophy were found to be predominantly a hyaluronic acid mucopolysaccharide. In contrast, the background substance contained a less acid mucopolysaccharide. The increase in bone marrow acid mucopolysaccharide in anorexia nervosa may represent a serous fat atrophy change rather than an increase in ground substance.

Bone marrow hypoplasia in anorexia nervosa

Within a 2-year period, from March 1974 until May 1976 10 patients with anorexia nervosa were seen at the children's university hospitals of München (2 patients) and Giessen (8 patients). The patients were 10-16 years old, with one exception all girls, and had the typical cachexia, hypothermia, bradycardia, gray, hairy skin, and amenorrhea in those who had reached menarche. The blood counts at diagnosis revealed a leukopenia (below 5000/mm3) in 6 patients and a thrombocytopenia (below 150000/mm3) in 4 patients. The bone marrow was examined in 7 patients and showed marked hypocellularity with only few megakaryocytes present and abundant vacuolated hyaline material. Bone marrow erythroblasts were decreased (below 20%) in 5 patients, although peripheral blood hemoglobin and hematocrit were normal or even elevated in all 10 patients. In 7 patients blood urea nitrogen was elevated above 30 mg%, the highest value being 145 mg%. Blood and bone marrow alterations as well as the renal abnormalities disappeared within days to a few weeks after a regimen of strict fluid and caloric intake was initiated and a gain in body weight of up to 10 kg was achieved.

Gelatinous transformation of bone marrow in prolonged self-induced starvation

In bone marrow from 3 patients with prolonged, severe self-induced starvation, fat atrophy, hypoplasia of haemopoietic cells and characteristic gelatinous transformation of marrow were noted. The gelatinous substance appeared amorphous and stained pink with the Wright-Giemsa stains. Histochemical and ultrasturctural studies indicated that it consisted of acid mucopolysaccharides and was extracellular in nature. Similar marrow abnormalities were produced in rabbits by limitating their food intake for 4 months. These marrow abnormalities in the experimental animals could be reverted to normal by restoring their nutritional status. It is proposed that the gelatinous transformation of marrow is caused by excessive production of mucopolysacchrides of the ground substance to compensate for the mobilization of marrow fat which occurs to meet the energy requirement. It is further postulated that excessive production of acid mucopolysaccharides may provide a microenvironment unsuitable for haemopoietic proliferation. The relevance of these findings to other conditions associated with marrow aplasia, is discussed.

Anemia in adolescence. 2. Hemoglobinopathies and other causes

Many complex forces are at work during adolescence which can contribute to the occurrence of anemia. Careful consideration of the entire patient should enable a physician to identify the unusual as well as the more common causes of anemia in this age group. Anemia in teenage girls is primarily due to menstrual iron loss. In boys, borderline diets and the demands of rapid growth predominate as causative factors. Hemoglobinopathies (thalassemia, sickle cell disease), G6PD deficiency, infectious mononucleosis, and illicit drug use account for small proportions of cases.

Anorexia nervosa: clinical observations in a successful treatment plan

This poorly understood disease has been studied in 27 girls and two boys. Metabolic aberrations included electrocardiographic abnormalities, hypovitaminosis A, hypercarotenemia, abnormal oral glucose tolerance curves, decreased xylose excretion, decreased excretion of luteinizing (LH) and follicle-stimulating hormones (FSH), decreased serum thyroxine levels, absence of diurnal variation of plasma concentrations of glucocorticoids, elevation of blood urea nitrogen, bone marrow hypoplasia, and leukopenia. With restoration of proper nutrition, most of these abnormalities (except FSH and LH) were corrected. An effective method for inpatient treatment is described. There were no deaths during this period of study.