Spinal cord compression due to extramedullary hematopoiesis in homozygous thalassemia. Case report

[Re-irradiation of bone marrow compression on a focus of extra medullary hematopoiesis: Presentation of a case]

We present the case of a 40-year-old patient with β-Thalassemia major who underwent decompressive palliative radiotherapy on symptomatic intracanal extra medullary hematopoiesis on three occasions between 2016 and 2020. We delivered normo-fractionated radiotherapy at a dose of 10Gy in five fractions on vertebrae T4 to T10 and L3 to S2, 20Gy in ten fractions on vertebrae C7 to T11, and 12Gy in six fractions on vertebrae C7 to T9. The treatment was well tolerated with complete recovery of the symptomatology during the first two irradiations, and almost complete recovery after the 3rd irradiation.

Spinal cord compression due to extramedullary hematopoiesis in patient with Beta thalassemia major

Extramedullary hematopoiesis can occur in patients with beta thalassemia major, which can lead to spinal cord compression. In such cases, the use of radiotherapy can be sufficient for the complete resolution of neurological symptoms.

[Spinal cord compression due to extramedullary hematopoiesis in a patient with myelofibrosis]

Development and growth of hematopoietic tissue outside of the bone marrow is termed extramedullary hematopoiesis (EMH). It occurs in patients with hematological diseases such as myelofibrosis and thalassemia. Liver and spleen are the usual sites of EMH. However, spinal cord compression caused by EMH is a rare complication. A 65-year-old man with myelofibrosis was admitted to our hospital with progressive paraparesis. Thoracic spine MRI revealed epidural masses causing cord compression. Histological examination of the epidural mass showed evidence of EMH consisting of megakaryocytic and erythroid hyperplasia. After surgical decompression and radiotherapy, lower limb weakness and sensory disturbance were significantly improved. MRI showed disappearance of the spinal cord compression. With this therapy, he had no recurrence until he died of myelofibrosis. Spinal EMH should be considered as a differential diagnosis in patients with hematological diseases presenting with paraparesis. Surgical decompression and radiotherapy are effective approaches for the treatment of paraparesis due to EMH.

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.

Progressive spinal cord compression due to epidural extramedullary hematopoiesis in thalassemia intermedia. A case report and literature review

Extramedullary hematopoiesis (EMH) can occur in patients with thalassemia intermedia as a physiologic response to insufficient erythropoiesis to meet circulatory demands. Rarely, EMH involve the epidural space causing spinal cord compression. We describe a case of EMH in a 21-year-old man with β-thalassemia intermedia presenting with progressive low back pain, worsening paraparesis and sphincter disturbance. Magnetic resonance imaging (MRI) demonstrated spinal cord compression by EMH epidural mass lesions extending from T3 to T10 levels. An emergency multilevel decompressive laminectomy was performed with excision of the masses and complete rehabilitation of the patient.

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.

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.

Lumbar nerve root compression due to extramedullary hemopoiesis in a patient with thalassemia: complete clinical regression with radiation therapy. Case report and review of the literature

The authors describe the case of a 24-year-old woman who had a history of beta3-thalassemia and presented with severe symptoms of lumbar nerve root compression due to extramedullary hemopoiesis in the intervertebral foramen. Radiation therapy (2000 cGy in six fractions) was delivered to the mass. The patient's neurological symptoms completely resolved following treatment. Follow-up images showed a reduction in lesion size. The results of this unique case supported by a review of the literature suggest that radiation therapy alone is an effective modality in the treatment of patients with compression of neural structures due to extramedullary hemopoietic tissue.

Spinal cord compression in beta-thalassemia: case report and review of the literature

STUDY DESIGN

A case report of thoracic spinal cord compression in a 34-year-old male with beta-thalassemia is reported.

OBJECTIVES

In patients with thalassemia, neurologic complaints should lead to a high index of suspicion for spinal cord compression from marrow expansion, ectopic bone formation and resultant stenosis. Initial presentation, diagnosis, radiographic findings, surgical treatment and follow-up are reviewed.

SETTING

This case is reported from Chicago, Illinois.

METHOD

A chart review is performed for the purposes of this case report.

RESULTS

Patient underwent decompressive laminectomy with good surgical outcome.

CONCLUSION

Rapid diagnosis and treatment of such a condition is essential to optimize the chances of recovery.

Extramedullary haemopoiesis in thalassemia intermedia presenting as paraplegia

Extramedullary haemopoiesis causing spinal cord compression is a rare manifestation of thalassemia. We describe a 17 year old male with thalassemia intermedia who presented with progressive paraplegia and sphincter disturbance. Magnetic resonance imaging revealed an epidural lesion extending from T5 to T8 compressing the spinal cord. The patient recovered completely after surgical decompression with postoperative radiation therapy. Histological examination of the lesion confirmed the diagnosis of extramedullary haemopoiesis. Clinical awareness of this phenomenon with early treatment is essential for optimizing the neurological outcome.

Cerebral thrombosis in beta-thalassaemia major

Two patients with homozygous beta thalassaemia complicated by cerebral thrombosis are reported. An alteration in coagulability due to a sudden increase in haematocrit and platelets was the probable cause in one patient. Although the other patient had many complications of thalassaemia, the cause for cerebral thrombosis was not identifiable.

Craniocephalic disproportion with increased intracranial pressure and brain herniation: a new clinical syndrome in anemic patients: report of two cases

OBJECTIVE AND IMPORTANCE

We describe a new clinical syndrome in two patients with chronic anemia. The major manifestation of the syndrome is herniation of the brain resulting in death caused by longstanding craniocephalic disproportion. The disproportion was caused by extreme thickening of the cranium because of erythroid hyperplasia.

CLINICAL PRESENTATION

Two patients with known chronic anemia presented with chronic increase in intracranial pressure with acute deterioration resulting in brain herniation.

INTERVENTION

Despite maximum medical therapy, both patients died as a result of uncontrollable increase in intracranial pressure.

CONCLUSION

Patients with chronic anemia presenting with progressive headaches should be monitored for this newly described clinical phenomenon.

Extramedullary hematopoiesis manifesting as a symptomatic pleural effusion

The occurrence of extramedullary hematopoiesis in the pleura is rare and is usually asymptomatic. It is generally diagnosed on postmortem examination. Herein we describe a 61-year-old woman with agnogenic myeloid metaplasia who sought medical assessment because of progressive dyspnea. Thoracentesis yielded sanguineous fluid with 10% myeloblasts. A 99mTc bone marrow scan demonstrated increased tracer activity throughout both lungs, an outcome consistent with extramedullary hematopoiesis. Fine-needle aspiration and video-assisted thoracoscopy were considered but deferred because of the potential risk of profuse bleeding. Treatment with low-dose external beam irradiation to the left posterior pleura was successful. To date, no hemothorax has recurred.

Spontaneous adrenal and hepatic myelolipomas in the common marmoset

Myelolipomas occurring simultaneously in the adrenal and liver were found in a 2.7-yr-old, bred female common marmoset (Callithrix jacchus). The animal bore single adrenal and multiple hepatic myelolipomas. The adrenal myelolipoma consisted of mature adipose cells and focal collections of normal hematopoietic elements and was unencapsulated. In the liver, the myelolipomas, which were partially encapsulated, included a large amount of hematopoietic tissue and adipose cells that resembled normal bone marrow cells in various ways. Additionally, one of the multiple nodules contained several bony spicules with osteoblasts. Furthermore, there were invasive figures of hematopoietic cells, such as myeloblasts, erythroblasts, and megakaryocytes, in the hepatic sinusoids around the lesions. Thus, this case has some unusual morphological characteristics and is the first report, to our knowledge, on multiorganic myelolipomas in common marmosets.

Cauda equina compression syndrome in a patient affected by thalassemia intermedia: complete regression with blood transfusion therapy

Surgical excision followed by radiotherapy has been reported to be successful in the treatment of spinal cord compressions due to extramedullary hematopoiesis in patients affected by thalassemia. The authors report a case of cauda equina compression in such a patient successfully treated with repeated blood transfusions.

Progressive paraparesis due to thoracic extramedullary hematopoiesis in myelofibrosis. Case report

A patient with myelofibrosis who developed a progressive paraparesis caused by spinal cord compression due to thoracic extramedullary hematopoietic tissue is reported. He recovered well after local radiotherapy alone.

Obstructive uropathy due to extramedullary haematopoiesis in beta thalassaemia/haemoglobin E

An 18 year old woman with beta thalassaemia/haemoglobin E developed a large pelvic tumour resulting in bilateral obstructive uropathy. Technetium-99m sulphur colloid marrow image, computed tomographic scan of the abdomen and needle biopsy of the mass confirmed the diagnosis of extramedullary haematopoiesis. Although radiation is the treatment of choice for decompression, the mass in this patient did not respond satisfactorily due to its multiple area of tumour autoinfarction. Obstructive uropathy due to extramedullary erythropoiesis has not to our knowledge been previously described.

The role of radiation therapy in the management of spinal cord compression due to extramedullary haematopoiesis in thalassaemia

Extramedullary haematopoiesis associated with thalassaemia leading to spinal cord compression is an extremely rare event in the course of the disease. The efficacy of radiation therapy is advocated in the management of such a complication. Two patients with thalassaemia, who had presented with spinal cord compression, were successfully treated by a modest dose of local radiotherapy. In one of the patients, however, radiotherapy was resorted to after an initial decompressive laminectomy and partial removal of the intraspinal haematopoietic mass proved unsuccessful. The other patient was managed solely by radiation therapy.

Paraplegia in a pregnant thalassemic woman due to extramedullary hematopoiesis: successful management with transfusions

The investigation and treatment of a pregnant thalassemic woman who developed severe paraplegia is presented. Magnetic resonance imaging showed a paravertebral mass infiltrating the epidural space, resulting from extramedullary hematopoiesis (marrow heterotopia). The patient was treated successfully with repeated blood transfusions and made a complete recovery. The literature (36 cases) is reviewed and the magnetic resonance imaging features of spinal extramedullary hematopoiesis are presented. The efficacy of transfusions in the management of spinal cord compression due to marrow heterotopia in thalassemic patients is discussed.

Spinal extradural hematopoiesis in adolescents with thalassemia. Report of two cases and a review of the literature

Extramedullary hematopoietic tissue occurring within the extramedullary space and causing cord compression is an unusual occurrence in childhood and adolescence, and only four cases have been reported during the first two decades of life. We had the opportunity to treat a 16-year-old girl and a 14-year-old boy with paraparesis secondary to extradural extramedullary hematopoiesis. Findings in these cases are discussed, and an attempt is made to stress once more the possibility of congenital hematopoietic rests as the origin of such hyperplastic tissue. The various modes of therapy are discussed and related literature is reviewed.

Low back pain due to extramedullary hemopoiesis

Two cases of extramedullary hemopoiesis in the lower spinal column are reported. One of them was due to thalassemia major and the other to thalassemia intermedia. CT and MRI studies showed paraspinal and presacral masses respectively which caused nerve root compression. It is concluded that the differential diagnosis of low back pain and radicular or pseudoradicular pain should include extramedullary hemopoiesis.

Spinal space occupying lesions in thalassemia major

A 17 year old patient suffering from thalassemia, who had been dependent on transfusions since the age of three, showed an increasing incomplete sensory and motor transverse cord lesion below T-10. The causes were found to be multiple epidural erythropoietic foci, confirmed by myelography, CT, and biopsy. The lesions were located in the thoracic, lumbar, and sacral regions. Complete remission of the neurological symptoms was achieved by an immediate hypertransfusion regimen and subsequent local radiation therapy of the neuroaxis. Thirty-six cases of thalassemia and spinal space occupying lesions have been reported in the literature. The therapeutic results of these are presented and compared with our findings.

Massive hemothorax due to intrathoracic extramedullary hematopoiesis in a patient with thalassemia intermedia

We report the case of a 49-year-old woman with thalassemia intermedia who developed a massive hemothorax due to hemorrhage from a large intrathoracic, paraspinal hematopoietic mass. Thoracotomy was required for initial control of bleeding. Postoperatively she received a total of 1,500 rads to the mass and has not had recurrence of the hemothorax. This complication of extramedullary hematopoiesis has not been previously reported, to our knowledge.

Paraplegia due to extramedullary hematopoiesis in thalassemia. Case report

Surgical excision followed by radiotherapy has been the recommended treatment for paraplegia due to extramedullary hematopoiesis in patients with beta-thalassemia. The authors report the successful treatment of such a case by partial excision and repeated blood transfusions.

Spinal cord compression due to intrathoracic extramedullary haematopoiesis in homozygous thalassaemia

A rare condition of massive intrathoracic extramedullary haematopoiesis causing spinal cord compression is presented in a 17-year-old Saudi male. Both clinical and laboratory findings, together with the computed tomographic evaluation of the lesion are described. Partial surgical resection as an alternative to radiotherapy has resulted in a dramatic response.

Paraplegia with thalassaemia

A case is reported of spinal cord compression resulting from extramedullary haemopoiesis in a patient with thalassaemia. A 28-year-old woman with beta thalassaemia intermedia presented with a two week history of paraparesis with bladder and bowel incontinence. Recovery followed laminectomy and the removal of haemopoietic tissue in the spinal epidural space. This is a rare complication and only eight cases have been reported in the literature.

Acute cerebrovascular insults in homozygous beta-thalassaemia: a case report

Neurological complications following vascular thrombotic crises are frequent and occur in sickle cell anaemia and its variants, but are less well recognized in thalassaemias. A case of beta-thalassaemia major is reported complicated by an ischaemic lesion involving the right cerebellar hemisphere. The probable pathogenesis is considered and the literature on the matter briefly reviewed. In agreement with other reports, the interference of risk factors provided by or occurring in association with multiple blood-transfusions is hypothesized. Consequently, caution is recommended in giving large blood-transfusions to thalassaemic patients.

Spinal cord compression in a new homozygous variant of beta-thalassemia. Case report

✓ A patient is reported with a new genetic variant of beta-thalassemia, who suffered from a progressive partial transverse cord lesion caused by epidural hematopoietic tissue. He recovered after partial surgical removal of this tissue and subsequent radiotherapy.

Spinal epidural extramedullary hematopoiesis with cord compression in a patient with refractory sideroblastic anemia. Case report

Spinal cord compression by epidural extramedullary hematopoiesis (EMH) is a rare phenomenon. A case of acute compressive myelopathy is reported in a 72-year-old man with EMH secondary to sideroblastic anemia. Technetium colloid scanning was used to document extensive ectopic marrow formation. The patient improved following surgery and radiotherapy. A review of the literature revealed 23 other cases of symptomatic spinal epidural EMH. The underlying hematological disorder varied but was always of long duration. Eighty-eight percent of the patients were males. Symptoms lasted longer than 1 week in 90% of cases, and 91% demonstrated incomplete neurological deficits. Plain x-ray films were rarely helpful in establishing the diagnosis. Technetium sulfur colloid bone marrow scanning has been used successfully to detect EMH and has led to preoperative diagnosis in one case. Decompressive laminectomy with or without postoperative irradiation is the suggested therapy, although there is evidence that radiotherapy alone may be adequate in some cases. Good recovery is the rule despite long-standing neurological deficits.

Tumor-simulating thoracic extramedullary hematopoiesis

Two patients with massive, tumor-simulating extramedullary hematopoiesis are presented. In 1 patient with homozygous beta-thalassemia, a progressive paraparesis developed because of a mass of ectopic marrow in the spinal epidural space. Surgical removal and radiotherapy were successful. The second patient, who died during surgical biopsy, had posterior mediastinal masses without any apparent cause. A correct preoperative diagnosis may avoid unnecessary surgical intervention. It is suggested that heterotopic marrow should be included in the differential diagnosis of a mass in the lower thoracic region.

Extramedullary hematopoiesis and spinal cord compression complicating polycythemia rubra vera

A 68-year-old man with polycythemia rubra vera developed gradually progressive paraparesis followed by an acute, painless paraplegia. Extradural thoracic spinal cord compression was found to be secondary to extramedullary hematopoiesis (EH). The neurological complications of EH are reviewed.

Progressive myelopathy due to extramedullary hematopoiesis: case report and review of the literature

Extramedullary hematopoiesis (EMH) in the spinal epidural space is a rare but treatable cause of progressive paraparesis in patients with a variety of hematological and systemic disorders. We report a case of extensive thoracic epidural EMH causing progressive spastic paraparesis in a patient with agnogenic myeloid metaplasia. The literature describes 11 additional cases of myelopathy due to epidural EMH. All patients had EMH in the midthoracic region with elevated cerebrospinal fluid protein and abnormal spine roentgenograms or myelograms. Treatment with decompressive laminectomy, radiation therapy, or both, resulted in marked or complete recovery in 7 of 10 patients. Patients who develop paraparesis and who have a disorder associated with EMH should be evaluated rapidly for this treatable condition.

Spinal cord compression in thalassaemia

Two cases of spinal cord compression resulting from extramedullary haemopoiesis in patients with thalassaemia of intermediate clinical severity are reported. The association between mild thalassaemia with long survival and the risk of spinal cord compression from extramedullary haemopoietic deposits is emphasised.