Anand, N

Ganesh, KM

Jayakris, Deepa

Nair, PMC

English

Atharva Scientific Publications (E-Jounals)

 Atharva Scientific Publications 
 
 
 
Indian Journal of Child Health 
A quarterly, peer-reviewed, international, open access journal 
published by Atharva Scientific Publications, India. 
Hematogones Masquerading as Acute Leukemia 
PMC Nair, KM Ganesh, N Anand, Deepa Jayakrishnan  
From Department of Pediatrics, Sree Gokulam Medical College, Venjaramoodu, Trivandrum, Kerala, India. 
 
 
 
 
 
 
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How to cite this article: Nair PMC, Ganesh KM, Anand N, Jayakrishnan D. Hematogones 
Masquerading as Acute Leukemia. Indian J Child Health. 2014;1(1):32-33. 
Letter to Editor 
Nair et al  Hematogones 
Indian J Child Health | Vol. 1 | Issue 1 | April – June 2014 32 
Letter to Editor 
Hematogones Masquerading as Acute Leukemia 
PMC Nair, KM Ganesh, N Anand, Deepa Jayakrishnan 
From Department of Pediatrics, Sree Gokulam Medical College, Venjaramoodu, Trivandrum, Kerala, India 
Correspondence to: Dr PMC Nair, Chaithanya, TC 25/1847, Thampanoor, Trivandrum-695001, Kerala, India. 
Email – drpmc50@gmail.com 
Received – 08 April 2014       Initial Review – 10 May 2014     Published Online – 13 May 2014 
 
ematogones are lymphoid progenitor cells 
and are normal constituents of bone 
marrow in children, which resemble 
malignant lymphoblast morphologically and 
phenotypically as both may have high nuclear: 
cytoplasmic ratio, condensed chromatin with no 
nucleoli. Sometimes, hematogones may be 
mistakenly reported as lymphoblasts leading onto a 
diagnosis of Acute Leukemia, especially if the 
child has pallor, fever and hepato-splenomegaly. 
Here, we report such a case. 
A 5 month old infant was referred to our 
hospital with complaints of fever and cough not 
responding to oral medications. On physical 
examination, he was afebrile with pallor and 
occasional crackles on chest. Abdominal 
examination showed hepatomegaly of 2 cm with 
span of 6.5cm and splenomegaly of 2 cm. Rest of 
the clinical examination was within normal limits. 
 
Fig 1:  H&E staining of bone marrow showing 
hematogones masquerading as blast cells 
Investigations showed haemoglobin of 5.2 
gm%, total lymphocytic count of 14300/mm
3
 with 
lymphocytic predominance, platelet count of 
520000/mm
3 
with ESR 140mm/hr, and positive C-
reactive protein. Peripheral smear showed 
microcytic hypochromic anaemia with reticulocyte 
count of 2%. Hb-electrophoresis was within normal 
limits. Bone marrow study showed blasts 
mimicking Acute Lymphoblastic Leukemia 
(Figure 1).  
Possibility of secondaries like neuroblastoma 
was also entertained. For confirmation flow 
cytometry was done, which showed hematogones. 
The infant was treated with antipyretics, antibiotics, 
blood transfusion and hematinics and recovered 
well. Hemoglobin improved after blood transfusion 
and hepato-splenomegaly slowly disappeared. On 
one year follow up, he is doing fine and growing 
normally. 
Hematogones (B lymphocyte progenitor cells) 
along with mature lymphocyte is a normal 
constituent of paediatric bone marrow (usually less 
than 1%). Their number decreases with age [1]. It 
was reported that in infants less than 2 years of age, 
hematogones averaged 9%, by 2 - 5 years the 
percent dropped to 3.9% and in patients more than 
50 years of age, the average was less than 1% [2]. 
Concomitant anaemia and splenomegaly makes 
diagnosis difficult to make. In such cases 
immunophenotypic analysis is needed, which show 
immature markers in acute leukemias and mature 
markers in hematogones. 
In flow cytometric studies, hematogones 
express a complete spectrum of antigen expression 
that defines the normal evolution of lymphocyte 
lineage. Depending on their stage of maturation, 
markers could be: CD10, CD19, CD34 positive 
cells, CD10, CD19 positive cells or CD19, CD22 
positive ones [3]. In contrast, the ALL samples 
consistently express a more immature, but 
homogeneous, immune-phenotype, with the 
H 
Nair et al  Hematogones 
Indian J Child Health | Vol. 1 | Issue 1 | April – June 2014 33 
majority of cases expressing TdT, CD34, or both 
[2].  
Increased hematogones had been observed in a 
variety of clinical conditions like Idiopathic 
thrombocytopenic purpura (ITP), regenerating 
marrow of treated ALL, after autologous bone 
marrow transplantation in Acute Myeloid 
Leukemia (AML) and in viral infections commonly 
due to CMV or HIV [4-6]. These data suggest that 
a mechanism involving immune-stimulation of the 
lymphoid population probably underlies the 
increased proportion of lymphocytes expressing 
immature B phenotype. Very few cases had been 
described in the literature in which children had 
clinical picture of cytopenias with increased 
hematogones in the bone marrow but no probable 
cause could be isolated [1]. It was postulated that 
an unknown viral infection might be responsible 
for these.  
In this particular child, associated infection may 
be the cause for whole scenario. Hemoglobin 
improved after blood transfusion and hepato-
splenomegaly slowly disappeared. On one year 
follow up, he is doing fine and growing normally. 
In children hematogones in bone marrow may 
confound the diagnosis of ALL as in this case, 
especially if there is associated fever, pallor and 
hepato-splenomegaly. Hence, before making a 
definite diagnosis of acute leukaemia one should be 
very careful, especially in infancy. Modern tests 
like flow cytometry comes handy in such 
situations.  
 
 
 
 
 
 
 
 
 
References: 
1. Rimsza LM, Larson RS, Winter SS, Foucar K, Chong 
YY, Garner KW, et al. Benign hematogone-rich 
lymphoid proliferations can be distinguished from B-
lineage acute lymphoblastic leukemia by integration of 
morphology, immunophenotype, adhesion molecule 
expression, and architectural features. Am J Clin 
Pathol. 2000;114:66-75. 
2. Lucio P, Parreira A, van den Beemd MW, van Lochem 
EG, van Wering ER, Baars E, et al. Flow cytometric 
analysis of normal B cell differentiation: a frame of 
reference for the detection of minimal residual disease 
in precursor-B- ALL. Leukemia. 1999;13:419-27. 
3. Kroft SH, Asplund SL, McKenna RW, Karandikar NJ. 
Haematogones in the peripheral blood of adults: a 
four-colour flow cytometry study of 102 patients. Br J 
Haematol. 2004;126(2):209-12. 
4. Guiziry DE, El GW, Farahat N, Hassab H. Phenotypic 
Analysis of Bone Marrow Lymphocytes from Children 
with Acute Thrombocytopenic Purpura. Egypt J 
Immunol. 2005;12(1):09-14. 
5. Longacre TA, Foucar K, Crago S, Chen IM, Griffith 
B, Dressier L, et al Hematogones: a multiparameter 
analysis of bone marrow precursor cells. Blood. 
1989;73:543-52. 
6. Rego EM, Garcia AB, Viana SR, Falcao RP. Age-
related changes of lymphocyte subsets in normal bone 
marrow biopsies. Cytometry. 1998;34:22-29. 
 
 
Funding: None; Conflict of Interest: None Stated 
How to cite this article: Nair PMC, Ganesh KM, 
Anand N, Jayakrishnan D. Hematogones 
Masquerading as Acute Leukemia. Indian J Child 
Health. 2014;1(1):32-33. 


Hematogones Masquerading as Acute Leukemia

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Hematogones Masquerading as Acute Leukemia

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