Bone marrow necrosis in an adult patient with precursor B-cell acute lymphoblastic leukaemia at the time of presentation.

To cite: Khoshnaw NSH, Muhealdeen DN. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014203891 DESCRIPTION A 58-year-old Kurdish woman with a history of diabetes, presented to our clinic with fever and rigour for 2 week’s duration, associated with diffuse bone pain and weight loss. Laboratory work showed pancytopenia with haemoglobin 107 g/L, white cell count 3.3×109/L (absolute neutrophil count 1.5×109/L) and platelet count 8×109/L, lactate dehydrogenase was 1227 U/L and uric acid 8 mg/ dL. The blood film showed normochromic normocytic anaemia with rouleaux formation. A bone marrow aspiration was diluted and looked like an artefact, no megakaryocytes detected, the blasts account for 40% on the available cells, and they were of acute lymphoblastic leukaemia (FrenchAmerican-British (FAB)–L2; figure 1). The bone marrow biopsy revealed diffuse necrosis, cells loosing normal staining with coagulative necrosis of marrow elements in an amorphous eosinophilic background, with a small focus of lymphoid cells and few residual megakaryocytic cells seen (figure 2). Flow cytometry revealed positive CD19, CD10, TDT, CD34 and CD79a while negative for T-cell markers. The patient received a five-drug remission induction regimen with intensive consolidation used for the patient (Larson protocol). We gave cyclophosphamide, daunorubicin, vincristine, prednisone and L-asparagines on 21 July 2013. She got complete remission with normal bone marrow aspirate and disappearance of necrosis on day 28 of her treatment. Bone marrow necrosis (BMN) is an uncommon clinicopathological condition which is diagnosed at postmortem period. BMN is mostly caused by malignancy especially haematological as acute leukaemias, relapsed Hodgkin’s lymphoma or solid tumours as gastrointestinal tract and prostate adenocarcinoma, stomach and colon cancer. Non-haematological causes as sickle cell disease, infections as tuberculosis and toxic effects of chemotherapy such as interferon α, granulocyte colony stimulating factor (G-CSF), all trans-retinoic acid (ATRA) and fludarabine. Rare causes of BMN are anorexia nervosa, haemolytic uraemic syndrome and antiphospholipid syndrome were reported. 2 Pathophysiology is unknown but could be due to marrow microvascular obstruction, cytokine release and T-cell and granulocyte activation. So by early diagnosis and good supportive treatment the prognosis is promising unlike that mentioned in the literature.