Epidural extramedullary haemopoiesis in thalassaemia

Epidural Spinal Cord Compression due to Extramedullary Hematopoiesis: Systematic Review of the Literature with an Illustrative Case

BACKGROUND

Epidural extramedullary hematopoiesis (EMH) is a rare, underreported phenomenon in which hematopoiesis occurring outside of the medullary environment can cause spinal cord compression. In this systematic review, we evaluate clinical characteristics and evidence-based guidelines for clinical management of EMH and present an illustrative case.

METHODS

A comprehensive search of the PubMed, Scopus, and Embase databases was conducted. Clinical and radiographic data on the patient characteristics, diagnoses, histories, treatment paradigms, and outcomes were extracted from eligible studies.

RESULTS

A total of 50 articles, including 54 patients (mean age at presentation, 37.9 years, 83.3% male) met inclusion criteria. Among patients, exam revealed motor/sensory deficit, back pain, bladder and bowel dysfunction, and gait disturbance due to masses impacting the thoracic (87.0%), lumbar (25.9%), sacral (16.7%), and cervical (5.6%) spine, often with multifocal EMH (24.1%). Fifty-two patients received treatment consisting of surgical resection, low-dose radiotherapy, or medical treatment such as transfusion (62%), hydroxyurea (24%), and steroids (24%). Primary treatment in 59.3% of patients was multimodal, with surgery (with/without adjunctive therapy) and early treatment (<1 month from symptom onset) correlating with a reduction in poor outcomes.

CONCLUSIONS

Epidural EMH is a pathology with limited reporting; this systematic review is the most comprehensive to date. Although available case series data were heterogeneous, our analysis suggested that multimodal treatment with surgical intervention was beneficial. Given the young patient population, we recommend prompt surgical management via decompression of the spine because of the associated low risk of complications and recurrence, and better neurological recovery.

Spinal epidural extramedullary haematopoiesis in β-thalassaemia intermedia

A 22-year-old man known to have β-thalassaemia intermedia since childhood presented with bilateral lower limb weakness after spinal anaesthesia for an elective minor operation of his left leg. MRI and CT scans were performed to rule out acute epidural haematoma; coincidental imaging features of marrow hyperplasia and spinal epidural extramedullary haematopoiesis were found. This article will present and discuss the imaging features, differential diagnosis, management and literature review of the rare occurrence of extramedullary haematopoiesis in the spinal epidural space.

37-year-old woman with multiple intracranial masses

Extramedullary hematopoiesis (EMH), defined as the presence of hematopoiesis outside bone marrow and peripheral blood, occurs asa compensatory phenomenon in several hematologic disorders and bone marrow dysfunction. EMH predominantly affects reticuloendothelial system including the spleen, liver and lymph nodes. Here,we report a rare case of multiple intracranial meningeal EMH. A37-year-old woman was anemic with gradually worsening vision for 8 months. Multiple extra-axial masses were found on imaging and the patient underwent the biopsy for the left frontotemporal lesion.Final diagnosis was multiple intracranial meningeal EMH. Treatment of fractionated external beam radiotherapy resulted in marked symptomatic improvement. This case indicates that although the diagnosis of meningeal EMH is difficult, there is a need to consider EMHin the differential diagnosis of anemic patients with tumor-like mass lesions in extramedullary sites.

[Beta-thalassemia intermedia complicated by spinal cord compression. Report of three cases and meta-analysis]

Extramedullary hematopoiesis is common in patients who suffer from beta-thalassemia. Extramedullary hematopoiesis is a compensatory mechanism of chronic anemia. Although the diagnosis is relatively easy, management is still the subject of considerable controversy. The aim of the present paper is to report three cases of spinal cord compression due to beta-thalassemia followed by a meta-analysis. In one of the three cases reported, spinal compression revealed beta-thalassemia. Forty-three cases have been reported in the last 10 years, i.e., four cases per year. The diagnosis was made by CT and myelography and confirmed by histology after surgical treatment. Two patients were followed in the hematology department. Young patients accounted for 95.45% of cases. The time to diagnosis was 3.33 months (3 days to 12 months). The most sensitive exam for diagnosis is magnetic resonance imaging before surgery. The MR image shows a hypointense lesion on T1-weighted sequences in 30.43% of cases or isointense on T2-weighted sequences in 34.78% of cases, and hypointense on T1-weighted sequences enhanced with gadolinium in 42.85% of cases. When MRI is absent, as in our patients, myelography can provide the diagnosis. The vertebrae are enlarged and translucent in 85.71% of cases with a hypodense lesion compressing the spinal cord. Laboratory tests show chronic microcytosis hemolytic anemia in 97.17% of cases. The diagnosis was established by histology performed after surgical removal. The patients recovered 97.5% of their neurologic deficiency after specific treatment. The mean follow-up was 2 years (4 weeks to 15 years).

Extramedullary hemopoiesis with undiagnosed, early myelofibrosis causing spastic compressive myelopathy: Case report and review

Extramedullary hemopoiesis (EMH) is a common compensatory phenomenon associated with chronic hemolytic anemia. Abnormal hemopoietic tissue usually develops in sites responsible for fetal hemopoiesis, such as spleen, liver and kidney; however, other regions such as the spine may also become involved. In this study, a patient presenting with spastic paraparesis due to EMH in the dorsal spine is described. A 62-year-old man presented with paraparesis. Magnetic resonance imaging revealed a large lesion involving the T2-L2 vertebral levels with a large extradural component causing thecal sac compression. Laminectomy with excision of mass was carried out. The histopathology revealed EMH. The patient had no known cause for EMH at the time of diagnosis but, subsequently, a bone marrow examination revealed early myelofibrosis. This case represents the rare occurrence of a large extradural extramedullary hematopoiesis in a patient with no known predisposing factor for hemopoiesis at the time of presentation.

Effect of hydroxyurea on extramedullary haematopoiesis in thalassaemia intermedia: case reports and literature review

Extramedullary haematopoiesis (EH) is the production of blood cell precursors outside the bone marrow that occurs in various disorders, such as thalassaemia, sickle cell anaemia, hereditary spherocytosis, polycythaemia vera, myelofibrosis and other haematological diseases. In chronic anaemia, it is a physiological response to increased erythropoietin. In some other conditions, such as myeloid metaplasia, polycythaemia vera or chronic myeloid leukaemia, EH is due to a clonal disorder of haematopoiesis that enables progenitor cells to escape from the marrow and lodge in other organs. EH usually involves the liver, spleen and lymph nodes or it can be paravertebral, intrathoracic, pelvic. It is often asymptomatic but can sometimes lead to symptomatic tumour-like masses. Treatment options are still controversial and limited, including hypertransfusion regimen, surgical treatment, radiotherapy and hydroxyurea (HU). We describe intrathoracic and symptomatic pelvic EH masses in a 48-year-old woman and intrathoracic bilateral masses causing respiratory insufficiency with pleural effusion in a 42-year-old male, both affected by thalassaemia intermedia. Both patients showed a clinical improvement with hydroxyurea therapy and occasional blood transfusions.

Existence of cord compression in extramedullary hematopoiesis due to beta thalassemia intermedia

Extramedullary hematopoiesis (EMH) is a rare disorder, characterized by the appearance of hematopoietic elements outside of the bone marrow, which occurs in patients with chronic myeloproliferative disorders or congenital hemolytic anemias. We report a case with thalassemia intermedia, EMH in spinal cord and a paravertebral mass. We report the case of a 20 year old female who initially presented with back pain and leg weakness was found to have paravertebral mass in the spinal cord.

Hématopoïèse extramédullaire: à propos de deux cas

Extramedullary haematopoiesis is a physiologic response to chronic anaemia, commonly observed in various haematological disorders. This phenomenon is habitually asymptomatic but it may induce compression of adjacent organs such as the spinal cord. We present the cases of two patients suffering from chronic anaemia, who developed foci of ectopic hematopoiesis, and we discuss through a review of literature, the presentation and the management of this disease, with focus on the role of decompressive radiotherapy.

Intracranial involvement in extramedullary hematopoiesis: case report and review of the literature

Intracranial involvement in extramedullary hematopoiesis (EMH) is rare, but it should be suspected in patients with myelofibrosis presenting with chronic severe headache. We present a 9-year-old girl with known myelofibrosis whose headaches were unresponsive to routine treatment. CT and MRI studies of the brain showed diffuse pachymeningeal thickening. CT examinations of the chest and abdomen had demonstrated bilateral thoracic paraspinal masses caused by EMH, suggesting the possibility that the intracranial involvement might also be related to EMH. The diagnosis was confirmed by sulfur colloid isotope scan.