Hypertransfusion for spinal cord compression secondary to extramedullary hematopoiesis

A Progressive Paraplegic Patient with Thalassemia Because of Extramedullary Hematopoiesis and Vertebral Fracture: A Case Report

CASE

We present a case of progressive paraplegia because of extramedullary hematopoiesis and pathological vertebral fracture in thalassemia patient. The various surgical techniques including larger pedicle screws, bicortical fixation, and convergent direction to improve pullout strength had been used secondary to osteoporotic bone and kyphotic deformity.

CONCLUSION

Prompt diagnosis and awareness of the compromised bone quality of the thalassemic patient is essential to guide the proper management and produce the desire outcomes.

Unusual presentation of extramedullary haematopoiesis in a young boy

Acute transverse myelopathy in a young person may be due to infection, postinfective or inflammatory demyelination, or vascular causes. Rarely, a completely reversible cause of acute transverse myelopathy may be seen, as described here in our case of transverse myelopathy due to extramedullary haematopoiesis (EMH). An 18-year-old man who had a history of a lone blood transfusion at age of 7 years presented with paraplegia. MRI showed multiple epidural space masses of EMH compressing the spinal cord. He was detected to have thalassaemia intermedia and was treated with blood transfusions, steroids and radiotherapy to the involved paraspinal areas. He recovered fully over 15 days and remained symptom free at 6 months.

Extramedullary hematopoiesis of the sphenoid sinus associated with hereditary spherocytosis: A case report

Extramedullary hematopoiesis is a rare cause of a sinonasal mass that presents unique diagnostic and treatment challenges. While there are numerous reports of patients with hereditary spherocytosis developing extramedullary hematopoiesis in the posterior mediastinum, involvement in the paranasal sinuses has not previously been described. Here, we present the first case of a patient with hereditary spherocytosis developing extramedullary hematopoiesis in the sphenoid sinus.

Spinal Cord Compression Secondary to Extramedullary Hematopoiesis: Case Report and Review of the Literature

Extramedullary hematopoiesis (EMH) is a rare cause of spinal cord compression (SCC). EMH represents the growth of blood cells outside of the bone marrow and occurs in a variety of hematologic illnesses, including various types of anemia and myeloproliferative disorders. Although EMH usually occurs in the liver, spleen, and lymph nodes, it may also occur within the spinal canal. When this occurs, the mass effect can compress the spinal cord, potentially leading to the development of neurological deficits. We present a case of SCC secondary to EMH. This report illustrates the importance of considering EMH in the differential diagnosis of SCC, even in the absence of signs of its most common etiologies.

Long segment spinal epidural extramedullary hematopoiesis

Background:

Extramedullary hematopoiesis is defined as the formation of blood cells outside the bone marrow. It is a common manifestation of many chronic hemolytic anemias, and typically involves the liver, spleen, and lymph nodes. Only rarely is the spinal epidural space involved.

Methods:

We describe a 25-year-old male, known to have thalassemia intermedia, who presented with a 1-month history of stiffness and weakness in both lower extremities. On physical examination, he had palpable splenomegaly accompanied by spinal tenderness at the D5 level, weakness in both lower extremities, hyperactive bilateral Patellar and Achilles reflexes with bilateral Babinski responses, and a graded sensory loss to pin appreciation below D5.

Results:

The magnetic resonance (MR) study revealed a posterior, isointense and soft tissue epidural mass extending from D2 to D12 on both the T1- and T2-weighted images. These findings were consistent with the diagnosis of “red marrow,” and long-segment spinal epidural extramedullary hematopoiesis.

Conclusions:

Although extramedullary hematopoiesis is rarely encountered within the spinal canal, it should be considered among the differential diagnoses when a posterior compressive thoracic lesion contributes to myelopathy in a patient with a history of thalassemia intermedia and the accompanying chronic hemolytic anemia.

[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).

Paraspinal extramedullary hematopoiesis in patients with thalassemia intermedia

Ineffective erythropoiesis in patients with thalassemia intermedia drives extramedullary hematopoietic tumor formation in several parts of the body. Paraspinal involvement has received increasing attention due to the associated morbidity secondary to spinal cord compression. Although the history and physical examination may help narrow the differential diagnosis, radiographic imaging remains essential to confirm the existence of hematopoietic tissue. Characteristic appearance has been observed mainly on magnetic resonance imaging. Several treatment options have been described, including transfusion therapy, laminectomy, radiotherapy, and the use of fetal hemoglobin inducing agents that decrease the hematopoietic drive. However, the ideal management scheme remains controversial. Until large prospective trials evaluate the efficacy and safety of the available treatment options, both in single and in combination therapy, an individualized approach should be entertained.

Successful treatment of spinal cord compression secondary to extramedullary hematopoietic mass by hypertransfusion in a patient with thalassemia major

A 15-year-old girl with thalassemia major who suffered from paraparesis with a history of progressive lower limb weakness for 2 years immigrated from mainland China to Hong Kong. She had not received regular blood transfusion since the age of 6 years after splenectomy. MRI of the spine showed thoracic spinal cord compression secondary to extramedullary hematopoietic mass. She made significant recovery with hypertransfusion therapy alone. MRI of the spine repeated 3 months later showed nearly complete resolution of the extramedullary hematopoietic mass.

Hematologic and clinical responses of thalassemia intermedia patients to hydroxyurea during 6 years of therapy in Iran

Hydroxyurea (HU) is a well-known chemotherapeutic agent that has been used largely for the treatment of various myeloproliferative conditions over the past 20 years. In beta-thalassemia, the role for HU is much less clear and remains controversial. This study was undertaken to describe the hematologic and clinical responses of thalassemia intermedia patients to HU treatment during 6 years in Southern Iran. One hundred sixty-three thalassemia intermedia patients were selected among the 3,000 cases of beta-thalassemia in Southern Iran from 1998 to 2003. All patients underwent laboratory tests and quantitative hemoglobin electrophoresis. Group 1 comprised patients receiving regular blood transfusions (after age 2 years old). Group 2 comprised those without any history of blood transfusions suffering from chronic anemia or long-interval transfusions. The state of energy, fatigability, and mood were recorded before the trial. Facial change was compared before and after treatment with HU. Electrocardiogram and echocardiography were carried out before and during treatment with HU. All patients were treated with HU; the starting dose was 8 to 12 mg/kg/d given orally once a day. Of the 163 patients, 149 tolerated the HU well and showed a dramatic response to the drug. Eighty-three of 106 transfusion-dependent patients (group 1) became completely transfusion-free, and 23 had one or two transfusions throughout the study. Sixteen of 43 patients (group 2) who were on long-interval transfusions became transfusion-free and 27 group 2 patients were transfusion-free, with developing acceptable hemoglobin levels. After treatment, 97% of patients described an increase in exercise tolerance, and no significant facial change was observed after therapy. No change in spleen size was observed in 83% of the patients. HU therapy was also associated with a marked increase in hemoglobin, mean corpuscular volume, and mean corpuscular hemoglobin. HU may be administered in thalassemia intermedia patients to minimize or even obviate the need for regular transfusions and concomitant iron overload, and HU therapy appears to be safe and effective when administered in thalassemic patients.

Epidural extramedullary haemopoiesis in thalassaemia

Intrathoracic extramedullary haematopoiesis is a rare condition. Involvement of the spinal epidural space with haematopoietic tissue is rather unusual. A 31-year-old-man with a known diagnosis of beta-thalassaemia was referred with focal back pain. Magnetic resonance imaging revealed diffuse bone-marrow changes, thoracic paraspinal masses and lobulated epidural masses, suggesting extramedullary haemopoiesis. The patient was treated with radiotherapy and blood transfusions. Follow-up MRI was performed for evaluation efficacy of the treatment.

Upper airway obstruction-related sleep apnea in a child with thalassemia intermedia

Obstructive sleep apnea can be caused by hypertrophy of tonsils and adenoids or neuromuscular diseases. The authors describe a child with thalassemia intermedia in whom severe obstructive sleep apnea syndrome developed. Computed tomography scanning revealed an obstruction of the nasopharynx resulting from extramedullary hematopoiesis. The child was treated with hydroxyurea and blood transfusions. Relief of symptoms was noted 1.5 months after initial treatment. Extramedullary hematopoiesis causes sleep apnea syndrome in thalassemic patients, and the treatment of hydroxyurea and blood transfusion for extramedullary hematopoiesis should be further studied.

Prognostic Significance of the Presence of Erythroblasts in Blood after Cardiothoracic Surgery

In patients suffering from a variety of severe diseases the detection of erythroblasts in peripheral blood is associated with poor prognosis. However, as yet the prognostic significance of erythroblasts in the blood of patients after cardiothoracic surgery has not been assessed. In a retrospective study we analyzed the database of 2074 patients, of whom 87 died in hospital during the postoperative period. All patients underwent cardiothoracic surgery using a heart-lung machine. Together with erythroblasts in blood, age, sex, body mass index, preoperative ejection fraction, smoking, diabetes mellitus, type of operation, emergency surgery, renal deficiency, pulmonary hypertension, and endocarditis were considered. The postoperative mortality of patients with erythroblasts in peripheral blood (n=57) was 45.6% (n=26), being significantly higher (p<0.001) than the mortality of patients without erythroblasts (3.0%). None of six patients with more than 2000 erythroblasts x 10(6)/l survived. The postoperative detection of erythroblasts is highly predictive of death, the odds ratio after adjustment for the other known prognostic factors being 7.2 (95% confidence interval 3.4-15.1). Erythroblasts were detected for the first time on average 11 +/- 2 days (median: 7 days; n=57) after surgery and 8 +/- 2 days (median: 6 days; n=26) before death. The detection of erythroblasts in blood after cardiothoracic surgery has a high prognostic significance in terms of in-hospital mortality, helping physicians to identify patients at high risk of death. This finding has to be confirmed by a prospective study with the use of a more sensitive and reliable technology and prospectively defined time intervals for counting blood cells.

Severe thalassaemia intermedia: clinical problems in the absence of hypertransfusion

In many of the parts of the world where thalassaemia is common, the blood supply is inadequate or unsafe, and desferrioxamine is too expensive for routine use. We classify some patients as having 'severe thalassaemia intermedia', i.e. those with moderately severe thalassaemia who can survive without regular transfusions, but who are at risk of many complications which are reviewed here. These include bone deformity and fractures, extramedullary haemopoietic tumours, leg ulcers, autoimmune haemolysis and, especially after splenectomy, thromboembolism and infection. An increase in the quality and safety of the blood supply, and a cheaper and/or oral iron chelator, would enable more of these patients to be treated as thalassaemia major and have improved survival and quality of life.

Regression of extramedullary haemopoiesis and augmentation of fetal haemoglobin concentration during hydroxyurea therapy in beta thalassaemia

Hydroxyurea increases fetal haemoglobin in many patients with sickle cell anaemia, but its effectiveness in thalassaemia appears to be less consistent. We describe the response to hydroxyurea in an adult male with homozygous beta thalassaemia, symptomatic paraspinal extramedullary haemopoiesis, bone pain, and progressive tissue iron loading. Prior to therapy with hydroxyurea the circulating haemoglobin (Hb) concentration was 7.0 g/dl and absolute fetal haemoglobin concentration was 5.0 g/dl. Administration of sodium phenylbutyrate had induced no increase in either parameter. Subsequent therapy with hydroxyurea was associated with increases in total haemoglobin to 9.0 g/dl, and in fetal haemoglobin to 7.6 g/dl. Ineffective erythropoiesis was reduced and extramedullary haemopoiesis regressed during therapy.