Idiopathic myelofibrosis with disseminated hepatosplenic, mesenteric, renal and pulmonary extramedullary haematopoeisis, portal hypertension and tuberculosis: initial presentation and 2 years follow-up

Case report: Primary myelofibrosis presenting with portal hypertension mimicking cirrhosis

Primary myelofibrosis (PMF) is an infrequent etiology of noncirrhotic portal hypertension (PH). In clinical settings, non-cirrhotic PH is often misdiagnosed as cirrhotic PH. This case report details a patient who exhibited recurrent esophageal variceal hemorrhage and was initially misdiagnosed with cirrhosis. Initially poised for liver transplantation, the patient's liver biopsy revealed no significant cirrhosis but showed signs of extramedullary hematopoiesis (EMH). Following the accurate diagnosis of PMF, the patient underwent standard treatment, leading to an absence of recurrent gastrointestinal hemorrhage due to esophageal varices for nearly three years.

Osteopetrosis: a rare case of portal hypertension

Osteopetrosis is a rare genetic bone disorder characterized by a defect in osteoclasts recruitment and function. Its manifestations are numerous and they mainly include skeletal and dental deformities, cranial nerve entrapment and infections. Over time, osteoclastic expansion invades bone marrow leaving little space for hematopoietic cells. As a result, extramedullary hematopoiesis takes place in the reticular system mainly in the spleen and liver. In these patients, portal hypertension can occur as a result of extramedullary hematopoiesis associated splenomegaly. We are reporting in this article a rare case of spontaneous bacterial peritonitis associated with portal hypertension in a patient with osteopetrosis.

Disseminated tuberculosis with myelofibrosis presentation: a case report

Background

Primary myelofibrosis is a rare myeloproliferative disorder in middle-aged and old adults and should be distinguished from secondary and reactive causes of bone marrow fibrosis because, in reactive fibrosis, treatment approaches depend on the underlying etiology.

Case presentation

Here we report the case of a middle-aged Iranian man who was diagnosed and treated as primary myelofibrosis at presentation, and whose final diagnosis was disseminated tuberculosis with reactive bone marrow fibrosis.

Conclusions

It is prudent to evaluate the potential causes of myelofibrosis in any patient with the diagnosis primary myelofibrosis. Tuberculosis can be an important etiology of bone marrow fibrosis, especially in endemic areas.

Isolated Nodal TBC Reactivation in a Patient with Post-Thrombocythemia Myelofibrosis Treated with Ruxolitinib: Case Report and Review of the Literature

Ruxolitinib side effects include the most frequent hematological toxicity along with a more recently evidenced immunosuppressive activity, interfering both with the innate and adaptive immunity, and several cases of reactivation of latent infections by opportunistic agents in patients in treatment with ruxolitinib have been published in the last years. Several pathophysiological mechanisms may explain an association between ruxolitinib and opportunistic infections. From what we know, the only case of an isolated lymph node TBC reactivation in a ruxolitinib-treated myelofibrosis (MF) patient was reported by Patil et al. in 2016 [Int J Med Sci Public Health. 2017;6(3):1]. Other 10 cases describing TBC reactivations in MF patients assuming ruxolitinib and successfully treated with 4-drug anti-TBC therapy are available in the literature to date. The case we reported describes an isolated lymph nodal TBC reactivation in a patient with the diagnosis of post-essential thrombocythemia-MF during ruxolitinib treatment after a long course of interferon-a (IFN-α2b) assumed for the previous diagnosis of ET. The case we report teaches that lymphadenopathy with or without constitutional symptoms developing during ruxolitinib therapy should be considered as a possible manifestation of a TBC reactivation in patients with a previous positive TBC-exposure test. In these cases, Ziel-Nielsen testing on urine and sputum has to be performed to rule out infectiousness and eventually isolate the patient. Moreover, previous long-time exposition to IFN-α2b may be related with a higher risk for TBC reactivation in these subset of patients. We encourage reevaluation of the cohorts of patients treated with ruxolitinib in previous and current large prospective studies to study the possible correlation between previous exposition to IFN-α2b and TBC reactivation.

Extramedullary haematopoiesis presenting as a periportal mass

Extramedullary haematopoiesis (EMH) is defined as haematopoiesis occurring in organs outside the bone marrow. The liver is one of the rare sites of EMH, and to the best of our knowledge, a few cases of adult EMH of the liver have been reported in the last 20 years. Here, we reported the case of a 68-year-old man with a known history of myelofibrosis presented with vague abdominal pain. An abdominal CT scan showed a hypoattenuating periportal mass encasing the portal vein. The final diagnosis of EMH was made through the histopathological examination. This is a rare presentation of EMH, which may be easily mistaken for other pathologies such as metastases. Familiarity with this type of presentation aids in correctly diagnosing it in an appropriate clinical setting.

A comparison of computed tomography with magnetic resonance imaging for the diagnosis of thoracic extramedullary hemopoiesis in patients with leukemia: A non-inferiority retrospective diagnostic study

At present, MRI is the primary choice of examination for the diagnosis of thoracic extramedullary hemopoiesis. When thoracic extramedullary hemopoiesis presents as posterior mediastinum masses in specific clinical contexts, the diagnosis is not challenging. Other radiological presentations may be more difficult for diagnosis and require biopsy. Needle biopsy is typically preferred for the diagnosis of extramedullary hemopoiesis however, the high vascularization of tissues is one of the complications of this method thus, it is avoided. The aim of the present study was to compare the diagnostic parameters of CT with MRI for the diagnosis of thoracic extramedullary hemopoiesis in patients with leukemia, with an open lung biopsy as a reference standard. Chest CT, chest MRI and open lung biopsy data from a total of 912 patients with leukemia with a sign(s) and symptoms of suspected paravertebral and/or pulmonary extramedullary hemopoiesis were reviewed. In the present study, thoracic extramedullary hemopoiesis was defined as diffusivity of both lung fields being increased compared with the blood pool and no other abnormal focal of lungs being increased compared with the blood pool. The beneficial score was calculated for CT and MRI and plotted for the decision making of irradiation. With respect to open lung biopsy, MRI had a higher sensitivity compared with CT (0.865 vs. 0.809; P<0.0001; q=1691) however, CT had a higher accuracy compared with MRI (0.833 vs. 0.733; P<0.0001; q=3020). The low rate of overdiagnosis was observed for both methods for the detection of thoracic extramedullary hemopoiesis however, the working area for detecting thoracic extramedullary hemopoiesis at least once in images was higher for MRI compared with CT. CT and MRI both have diagnostic importance in the detection of thoracic extramedullary hemopoiesis in patients with leukemia however, chest MRI misdiagnoses the condition while CT can confirm it (level of evidence, 3).