What is the significance of bone marrow examination in presence of peripheral cytopenias? It is still regarded as a mandatory investigation to diagnose hematological disorders. In this case, bone marrow trephine was initially done as a diagnosis of exclusion for ITP, whereas it revealed multiple granulomas suggesting mycobacterium tuberculosis infection

Ali, Natasha Bahadur

Zia, Farrukh

English

eCommons@AKU

eCommons@AKU Section of Haematology/Oncology Department of Medicine 10-8-2019 Granuloma whorls Farrukh Zia Aga Khan University Natasha Bahadur Ali Aga Khan University, natasha.ali@aku.edu Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_haematol_oncol  Part of the Hematology Commons, and the Oncology Commons Recommended Citation Zia, F., Ali, N. (2019). Granuloma whorls. Clinical Case Reports, 7(11), 2287-2288. Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_haematol_oncol/60 Clin Case Rep. 2019;7:2287–2288.    | 2287wileyonlinelibrary.com/journal/ccr31 |  INTRODUCTIONWe present a case of a 62‐year‐old gentleman who presented to haematology clinic with history of fever and repeated platelet transfusions due to thrombocytopenia. Bone marrow examination showed multiple granulomas with giant cell for-mation. The specimen was reported as granulomatous inflam-mation, and microbiological/clinical correlation was advised.Examination of bone marrow is an important investigation in patients presenting with pyrexia of unknown origin (PUO),1 decreased peripheral cell lines and as a staging procedure in lymphomas. In PUO, this investigation has been limited to im-munocompromised individuals, for example, human immuno-deficiency virus positive patients.2 The differential diagnosis of granuloma formation in bone marrow includes tuberculosis, sar-coidosis, drug hypersensitivity, and hematolymphoid neoplasms.Received: 21 January 2019 | Revised: 24 August 2019 | Accepted: 17 September 2019DOI: 10.1002/ccr3.2470  C L I N I C A L  I M A G EGranuloma whorlsFarrukh Zia1 |   Natasha Ali2This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.© 2019 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd1Section of Clinical Haematology, Department of Oncology, Aga Khan University Karachi, Karachi, Pakistan2Section of Haematology, Department of Pathology & Laboratory Medicine/Oncology, Aga Khan University Karachi, Karachi, PakistanCorrespondenceNatasha Ali, Department of Pathology and Laboratory Medicine/Oncology, Aga Khan University, stadium road 74800, P O Box 3500, Karachi, Pakistan.Email: natasha.ali@aku.eduAbstractWhat is the significance of bone marrow examination in presence of peripheral cy-topenias? It is still regarded as a mandatory investigation to diagnose hematological disorders. In this case, bone marrow trephine was initially done as a diagnosis of ex-clusion for ITP, whereas it revealed multiple granulomas suggesting mycobacterium tuberculosis infection.K E Y W O R D Sgiant cell, granuloma, thrombocytopeniaF I G U R E  1  Multiple granulomas at 10× F I G U R E  2  Multiple granulomas at 20×2288 |   ZIA And ALI2 |  CASE HISTORYA‐62‐year‐old gentleman presented in hematology clinic with complaints of fever and repeated platelet transfusions since one and a half months. On examination, he had pete-chiae on lower limbs. Complete blood counts showed Hb: 12.5 gms/dL, HCT: 36.9%, WBC: 10.8 × 109/L, platelets: 02 × 109/L. Peripheral blood film showed normocytic, nor-mochromic red blood cells, white blood cells were nor-mal and platelets were low on film. Subsequently, bone marrow trephine was performed. Bone marrow aspirate was a hemodiluted specimen. However, bone trephine re-vealed effaced architecture with cellularity of 85%‐90%. Cellular areas showed diffuse infiltration with multiple large and small areas of granulomatous inflammation con-sisting of epithelioid cells, plasma cells, and multinucle-ated Langhan's type giant cells with background increase in histiocytes (Figures 1-4). Immunohistochemistry panel was applied that showed positivity to CD 68 immunohisto-chemical stain. Periodic acid‐Schiff‐diastase (PAS‐D) and CD 30 were negative. We reported this case as granuloma-tous inflammation and suggested infection with mycobac-terium tuberculosis was the most likely possibility due to endemicity.CONFLICT OF INTERESTNone declared.AUTHOR CONTRIBUTIONSFZ: drafted manuscript and took pictures. NA: involved in concept and idea, drafted and critically reviewed manuscript, and responded to reviewers.ORCIDNatasha Ali   https://orcid.org/0000-0003-4990-330X REFERENCES 1. Basu D, Saravana R, Purushotham B, Ghotekar LH. Granulomas in bone marrow–a study of fourteen cases. Indian J Pathol Microbiol. 2005;48(1):13‐16. 2. Akpek G, Lee SM, Gagnon DR, Cooley TP, Wright DG. Bone mar-row aspiration, biopsy and culture in the evaluation of HIV infected patients for invasive mycobacteria and histoplasma infections. Am J Haematol. 2001;67:100‐106.How to cite this article: Zia F, Ali N. Granuloma whorls. Clin Case Rep. 2019;7:2287–2288. https ://doi.org/10.1002/ccr3.2470F I G U R E  3  Langhan's giant cell at 100×F I G U R E  4  Multinucleated giant cell at 100×

Granuloma whorls

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Granuloma whorls

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