Granulomatous lesions in bone marrow

A survey has been made of granulomatous lesions found in sections of bonemarrow from 150 patients studied at the Mayo Clinic. These lesions have beenfound in a variety of disorders, some with known etiologic agents and others withunknown causes.

With the exception of tuberculosis, histoplasmosis and brucellosis, in whichthe causative organisms were seen and identified bacteriologically, the granulomatous lesions were not thought to have any distinctive histopathologic characteristics.

Prominent lesions, Langhans’ giant cells and necrosis were more common inthe marrow of patients with disorders known to be associated with a granulomatous inflammatory process than they were in associations with other conditions.

Submitted on October 7, 1955 Accepted on March 9, 1956     

Autohemagglutinins and hemolysins with hemoglobinuria and acute hemolytic anemia,in an illness resembling infectious mononucleosis

A case is reported of a young man with acute hemolytic anemia and hemoglobinuria who presented: an initial blood picture consistent with infectious mononucleosis, associated with a heterophile agglutination test positive in high dilution;auto-hemagglutinins, active in the cold, at room temperature and at 37 Centigrade;a hemolysin active at 37 C. after chilling, requiring the presence of a thermolabilecomponent of serum for hemolysis; a positive Donath-Landsteiner test but no evidence of syphilis. In addition there was clubbing of the digits with certain otherroentgenologic changes in the bones; absence of any other etiologic factors knownto be concerned with such anemia; uneventful improvement under massive transfusion therapy, with apparent recovery from his hematologic disorder whenstudied two years later.

Note: ACKNOWLEDGMENTOur thanks are due to Dr. Maxwell Finland and Dr. Philip F. Wagley for suggestions in preparingthis report. We are especially indebted to Dr. T. Hale Ham for his patient and critical advice and encouragement.

     

The absence of the heterophile reaction in the spinal fluid in infectious mononucleosis

The spinal fluid was studied in twenty cases of infectious mononucleosis provedby clinical picture, blood studies and serological examination. It may be concluded that in acute cases of infectious mononucleosis, the heterophile antibodydoes not pass into the spinal fluid, but that there may be an increase in cell count,particularly lymphocytes, and in protein content, which is not necessarily proportional to the cell count elevation. These findings have no correlation withcentral nervous system signs or symptoms.

     

Thrombocytopenic purpura complicating infectious mononucleosis; report of a case and serial platelet counts during the course of infectious mononucleosis

A case has been presented in which thrombocytopenic purpura was a complication of infectious mononucleosis. A review of the literature revealed 6 other casesin which there was an association between these conditions. Serial platelet countswere made in 7 consecutive cases of infectious mononucleosis. There was a slightdepression of the platelets early in the illness, followed by a thrombocytosis and asubsequent return to normal. Hypersplenism is considered as a possible cause forthe thrombocytopenia in infectious mononucleosis.

     

The pathology of infectious mononucleosis

This pathologic study is based on 9 autopsies and many biopsies in cases ofinfectious mononucleosis.

The gross changes were almost exclusively confined to enlargement of lymphoidtissues, especially the spleen. Nasopharyngeal lymphoid hyperplasia was constant,in one instance suggesting tumor. Other tissues presented no significant gross features related to the primary disease except for (1) rather consistent enlargement ofthe liver, (2) infrequent icterus, and (3) occasional cutaneous rash. Histologic observations revealed more or less generalized lesions resembling those of certainknown virus diseases, notably perivascular aggregates of normal and abnormallymphocytes. Reaction of this type inconstantly involved all tissues studied exceptthe bone marrow; here lymphocytes were virtually absent in sections, but werepresent in aspirated marrow because of dilution with peripheral blood.

More specific changes were invariably noted in lymphoid tissues. The abnormallymphocyte characteristic of the disease could be identified in thin, lightly stainedsections. Lymph node reactions varied from a predominantly follicular hyperplasiato a blurred pattern simulating a malignant lymphoma; the latter was due to alymphocytic and reticulo-endothelial proliferation in the medullary cords. Thespleen displayed a lymphocytic infiltration in the thinned capsule and trabeculae,frequently dissolving the latter and rendering the organ liable to rupture. The pattern was partially effaced in most instances and the follicles widely spaced. Bloodsinuses contained considerable numbers of normal and abnormal lymphocytes, andaccumulations of these cells constantly cuffed intratrabecular arteries and lay beneath the intima of veins. Tonsils displayed ulceration and necrosis in several cases,and the lymphocytic proliferation closely resembled malignant tumor in a tonsilthat enlarged rapidly.

A pneumonic exudate in 1 case was almost exclusively of round cell type, whilein another the pneumonia was of the usual lobular type with a neutrophilicexudate. Small myocardial infiltrates which we noted probably explain the electrocardiographic changes described in infectious mononucleosis. Other findings ofparticular interest were the periportal lymphoid collars in the liver which sometimes attained the proportions seen in leukemia, and the presence of meningo-encephalitis in 4 of the 6 brains examined.

We believe that the majority of cells in the lymphocytic "infiltrates" of connective tissues and the perivascular collars are metaplastic rather than inwandering,i.e., that they are formed in situ and stem from cells of the reticulo-endothelialsystem.

     

Chronic marrow failure,myelosclerosis and extramedullary hematopoiesis

Thirty cases, including 20 autopsied, of chronic bone marrow failure, myelosclerosis and osteosclerosis have been presented and compared with similar reportsin the literature. The bone marrow histopathologic sequence observed involvedrepeated necrobiosis of maturing hematopoietic cells, followed by overgrowth ofmarrow reticulum and frequent ossification. Immature erythrocytes and leukocyteswere often found in the circulation, and extrameduallary hematopoiesis was characteristic. One case was complicated by leukemia. Etiologic factors implicatedincluded exogenous toxic chemicals, liver dysfunction, endocrine abnormalities,blood loss or destruction and cardiovascular disease. Suspicion was directed towardthe pathogenetic importance of protracted bone marrow exposure to certain substances normally conjugated rapidly in the liver and excreted.

Note: ACKNOWLEDGMENTThe authors acknowledge gratefully the continued assistance of Dr. John Norcross and Dr. DonatP. Cyr of Lahey Clinic, Boston, who permitted use of material from living cases.We are indebted to Dr. Shields Warren, New England Deaconess Hospital, Boston, for permissionto review 10 cases; to Dr. Olive Gates, Harvard Medical School, for advice and assistance with 7 cases,including material from the Collis P. Huntington Hospital; to Professor William Boyd for 5 cases fromBanting Institute, Toronto; to Dr. Paul D. Rosahn, New Britain General Hospital, New Britain, Conn.,and Dr. William Dameshek for one case; to Dr. A. J. Blanchard for several cases from Christie St. Hospital, Toronto; to Drs. Lorne Whittaker and Sabin of St. Catherine’s Hospital for one case; and to Dr.John Brownlee for hematologic studies from one case.

     

Studies on bone marrow in vitro; the effect of anoxia and hyperoxia on explanted bone marrow

The effect of various oxygen tensions on explanted bone marrow fragments wasstudied. It was found that gas mixtures containing 1, 3, 5, 10 and 12 per cent oxygenhave an injurious effect on hemic cells. Bone marrow maintained in these gas mixtures showed various degrees of degeneration, which was the more pronounced thelower the oxygen tension. Mitotic activity was also found to be reduced under theinfluence of low oxygen tension.

Bone marrow cultures maintained in a gas mixture containing 15 per cent oxygendid not show appreciable changes and were similar to the controls.

Increased rate of maturation and multiplication occurred in bone marrow cultures maintained in an excess of oxygen, i.e. 50 per cent.

The significance of these findings in the light of observations on the effect ofanoxia in vivo has been discussed, and reported findings on the effect of low oxygentensions on other tissues in vitro have been briefly reviewed.

     

The liver in infectious mononucleosis

Summary 1. Twenty-two patients with infectious mononucleosis were studied by liver biopsy and paper electrophoresis of the serum proteins. The findings were compared with a similar group of 30 patients with infectious hepatitis.2. The essential histologic features of infectious mononucleosis were the presence in the hepatic sinusoids and portal tracts of chronic inflammatory cells resembling small lymphocytes, with essentially no parenchymal cell damage. Admixed with this lymphocytic infiltrate, but in relatively minimal numbers, were a few plasma cells and polymorphonuclear leukocytes. In addition, in infectious mononucleosis there were, with rare exceptions, no lipochrome-containing Kupffer cells. Thus, in the majority of cases, the histologic picture was distinct from that seen in infectious hepatitis. Only in comparing a few of the more severe infectious mononucleosis cases with subsiding infectious hepatitis cases was there any tendency for the two pictures to merge, and the distinction on histologic grounds between the two entities could be made in the great majority of cases.3. The most commonly seen abnormalities in the paper electrophoretic patterns of sera obtained from patients with infectious mononucleosis were decreased albumin, increased gamma globulin, not infrequent but variable changes in alpha₂ globulin, and the presence of abnormal proteins migrating with mobilities intermediate to alpha₂ and beta, and beta and gamma globulins. The abnormalities observed in infectious hepatitis were similar to those of infectious mononucleosis, except that in hepatitis alpha₂ globulin was decreased more consistently, gamma globulin increased less frequently, and beta globulin, which was normal in practically all the cases of infectious mononucleosis, was increased in a considerable number of cases.4. Treatment of patients with infectious mononucleosis need not include prolonged bed rest and restriction of activity in an effort to avoid the development of chronic liver disease.     

Paroxysmal nocturnal hemoglobinuria associated with infectious mononucleosis.

A previously healthy 16-yr-old girl was found to have pancytopenia, low reticulocyte count, a cellular bone marrow, and a negative Coombs test, all coincident with clinical and laboratory evidence of infectious mononucleosis. Symptoms and signs of infectious mononucleosis subsided, but pancytopenia and hemolytic anemia persisted. Sucrose hemolysis and acid hemolysis tests supported a diagnosis of paroxysmal nocturnal hemoglobinuria (PNH). After 18 mo, the platelet count is normal, but leukopenia and hemolytic anemia continue. The development of PNH in this patient suggests it may have resulted from an effect of infectious mononucleosis.     

A histochemical study of acid and alkaline phosphatase distribution in normal bone marrow smears

1. Three minute fixation in formol vapor at 44 C, followed by 15 minute washing proved to be the most satisfactory fixation procedure for both "acid" and "alkaline" phosphatase technics as applied to bone marrow smears.

2. For both technics a relation between staining intensity and cellular richnesswas found.

3. The reaction of normal human bone marrow cells to both phosphatase technics is described. Both are predominantly nuclear in location. Nuclear patternapproached that observed with common staining methods and Feulgen’s reaction.Cytoplasmic reaction was nearly negative. Nonspecific and specific granules donot stain after the "alkaline" technic. Nonspecific granules are negative for "acid"phosphatase, while specific neutrophilic are variable, and eosinophilic, constantlypositive. Nucleoli are negative after the "acid" technic, being positive for the"alkaline" enzyme. Mitotic chromosomes are positive for both technics. "Acid"phosphatase reaction in cytoplasmic zones of lymphocytes, erythroblasts, plasmacytes and megakaryocytes, is described.

Note: ACKNOWLEDGMENTSMany points pertaining to this paper were discussed with the late Dr. José Oria, to whom we oweinvaluable stimulation and guidance. We are indebted to Prof. W. Buno of Montevideo (Uruguay) forkind advice on the Golgi apparatus of blood cells. We are deeply indebted to Professor O. P. Jones ofBuffalo for his painstaking help and advice. We thank Dr. M. A. Jamra (Section of Hematology, CentralLaboratory, Hospital das Clinicas da Faculdade de Medicina) and Dr. J. F. Pontes (Section of ClinicalTherapeutics, Hospital das Clinicas da Faculdade de Medicina), for part of the material used in thisstudy. We thank Messrs. L. Frankenthal and G. Lonenzini for their aid in the preparation of some of themicrophotographs.

     

Infectious mononucleosis and acute hemolytic anemia; report of two cases and review of the literature

1. Two cases of infectious mononucleosis complicated by acute hemolyticanemia are presented. One of these patients had, in addition, an underlyingMediterranean anemia.

2. Hemolytic anemia is a rare complication of infectious mononucleosis.

3. Thirteen similar cases have been collected from the literature, and thecumulative data summarized.

4. Recovery occurred in all cases. Splenectomy was considered necessary inonly two.

5. The etiology of hemolytic anemia in infectious mononucleosis is obscurebut there is good evidence to indicate it may be different in different cases.Hypersplenism initiated by infectious mononucleosis could best explain theauthors’ cases whereas the elaboration of hemolytic antibodies would bestexplain some of the reported cases.

Submitted on October 8, 1954 Accepted on February 14, 1955     

Diagnosis of atypical cases of infectious mononucleosis.

The variable manifestations of infectious mononucleosis rarely cause clinicians to suspect primary Epstein-Barr virus or cytomegalovirus infection; consequently, costly diagnostic tests and unnecessary treatments are undertaken. Seventeen cases of clinically atypical and 11 cases of clinically typical infectious mononucleosis were diagnosed through screening for atypical and apoptotic lymphocytes in the peripheral blood samples by means of an automated hematologic analyzer. Atypical and typical cases did not differ significantly with respect to peripheral white blood cell counts; percentages of lymphocytes, atypical lymphocytes, CD4(+) lymphocytes, human leukocyte antigen--DR positivity in CD3 lymphocytes, or apoptotic cells in blood smear after incubation; or levels of aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase. Only the percentage of CD8(+) lymphocytes was significantly higher in patients with typical infectious mononucleosis than it was in patients with atypical infectious mononucleosis. Because certain atypical cases of infectious mononucleosis display laboratory abnormalities that are characteristic of typical infectious mononucleosis, enhanced awareness can help in the diagnosis.     

Concomitant infectious mononucleosis and hemolytic icterus

Hemolytic anemia concomitant with infectious mononucleosis, was observed ina 22 year old white male whose history indicates no pre-existing hemolytic disease.Recovery occurred spontaneously.

     

Eosinophilic leukemia; report of a case with autopsy confirmation; review of the literature

1. The data in a case of fatal leukemia with predominant eosinophilia in theperipheral blood and bone marrow are presented; we believe that this case was oneof eosinophilic leukemia.

2. During the period of observation, these eosinophils showed progesssiveimmaturity as the symptoms became more severe. Eventually this "left shift"became so marked that a large proportion of the cells were terminally myeloblastsin both the blood and the bone marrow.

3. Autopsy revealed invasion of many of the tissues and organs with thesemature and immature eosinophil granulocytes and with myeloblasts.

Note: ACKNOWLEDGMENTOur thanks for helpful criticism are particularly extended to Dr. Charles Doan and to Dr. WilliamDameshek.

     

Granulomatous pneumonitis following bone marrow transplantation

We describe the rare occurrence of a granulomatous pneumonitis seen in a patient following allogeneic bone marrow transplantation. Interestingly sarcoidosis was diagnosed in the marrow donor less than a year after donating his bone marrow.     

Epstein-Barr virus in the bone marrow of patients with aplastic anemia

STUDY OBJECTIVE: To determine whether Epstein-Barr virus is present in the bone marrow of patients with aplastic anemia. DESIGN: Assay of fresh and fixed bone marrow specimens for Epstein-Barr virus using immunofluorescence for nuclear antigen, Southern analysis with an Epstein-Barr virus specific probe, and in-situ hybridization. SETTING: Governmental medical referral center. PATIENTS: Five patients were studied prospectively: three who previously had infectious mononucleosis, one with a recent viral pneumonitis, and one who was asymptomatic. Stored DNA samples from other patients with aplastic anemia were also screened. MEASUREMENTS AND MAIN RESULTS: Epstein-Barr virus DNA and protein were detected in the bone marrow of 5 patients studied prospectively and in 1 of 40 patients studied retrospectively. As estimated by in-situ hybridization, about 3% to 5% of marrow cells were infected with virus in those patients who had not received acyclovir. In contrast, Epstein-Barr virus DNA was not detected in peripheral blood DNA of these patients, nor were Epstein-Barr virus proteins or DNA found in the bone marrow of normal donors, patients with other hematologic diseases, or in 1 patient with acute infectious mononucleosis. Analysis of DNA fragments by hybridization with Epstein-Barr virus probes showed a pattern dissimilar to the type of Epstein-Barr virus usually associated with infectious mononucleosis. CONCLUSIONS: Aplastic anemia may be associated with Epstein-Barr virus more commonly than suspected by history. Localization of the virus in the bone marrow supports a causative role for Epstein-Barr virus in bone marrow failure.     

Granulomatous lesions in bone marrow: Clinicopathologic findings and significance in a study of 48 cases

PurposeGranulomas in bone marrow are an infrequent finding related to various disorders. The aim of this study was to review our clinical experience with granulomatous bone marrow disease and to describe the contributions of recent diagnostic tools, such as ¹⁸F-Fluorodeoxyglucose positron emission tomography (¹⁸F-FDG-PET) and molecular biology.MethodsClinical, laboratory and morphological data on patients with a granuloma based on bone marrow biopsy analysed in the University Hospital Lyon from May 2004 to July 2010 were reviewed.ResultsWe identified 57 cases among 9641 bone marrow biopsies, representing an incidence of 0.59% in the series and an annual incidence of 9.5 cases per year. Nine biopsies performed for staging a known pathology were excluded from further analysis. Among the 48 remaining patients, associated disease was demonstrated in 79%, with infections being the most common (33%), following by sarcoidosis (21%), malignancy (19%) and therapy-induced granulomas (6%). One previously unpublished entity is described: infection with Bartonella henselae diagnosed using molecular biology from node and skin biopsies in two renal transplant patients. ¹⁸F-FDG-PET, performed in 13 cases, showed hypermetabolic foci consistent with sarcoidosis in two cases. Positive PCR result for an infectious pathogen was obtained in three bone marrow samples (Mycobacterium tuberculosis, n = 1; Mycobacterium genavense, n = 2).ConclusionIn comparison to previous research, our study reports high proportions of cases caused by sarcoidosis and unknown causes. ¹⁸F-FDG-PET could show signs consistent with sarcoidosis and molecular biology is useful for the detection of fastidious bacteria in immunocompromised patients.     

Homografts of bone marrow in dogs after lethal total-body radiation

Twenty-two dogs (20 males and two females) were uniformly exposed overtheir entire surfaces to supralethal irradiation: 800 to 1,200 roentgens of250 kv. x-rays measured in air at mid-body position. On the third day andafter the last exposure, these irradiated animals were given infusions of normal bone marrow. The marrow for their infusions was taken from femalelitter-mates, from mothers or from unrelated dogs. Evidence for a returnof marrow function and for a successful marrow graft was evaluated on thebasis of: (1) the reappearance of formed elements: platelets, leukocytes, andreticulocytes, in the peripheral circulation; (2) the appearance in males ofleukocytes bearing the sex-chromatin marker of the female donor; (3) prolonged survival, as compared to six irradiated control animals that were notgiven marrow; and (4) cellularity of marrow spaces and histologic evidenceof marrow function at autopsy.

It was found that marrow transplants usually succeeded after 800 to 1,200roentgens of total-body irradiation when the infused marrow was taken fromlitter-mate sisters or from mothers (15 successes in 17 attempts). Marrowtransplants between unrelated animals appeared more difficult but were notimpossible. One success was obtained in five attempts, and this success wasachieved with the coincidental use of splenectomy, ACTH and a large doseof marrow.

Dogs with successful transplants lived longer than did control animals; inthis series two to 10 times as long. When they died, they died of commoncanine infectious diseases and not of marrow failure. Distemper, hepatitisand leptospirosis, with or without superimposed bacterial respiratory disease,were the common causes of death.

The lymph nodes and the splenic follicles of irradiated animals had, inmost instances, not regained normal histologic appearance at the time ofdeath from these infectious diseases. The working hypothesis is advancedthat infusions of marrow repopulate marrow spaces in the canine after irradiation but are poor sources of the type of cell needed to restore lymphoidfunction and immunologic effectiveness in lymph nodes and spleen.

Submitted on August 4, 1958 Accepted on November 18, 1958     

A rapid slide test for heterophile antibody in infectious mononucleosis

The sera of 473 individuals were examined for sheep cell agglutinins both by theslide test and the Paul-Bunnell method. In this group there were 46 patients withpositive slide tests and 35 of these individuals also had a diagnostic serum dilutiontest for heterophile antibody. In 11 cases the slide test was positive but the Paul-Bunnell test gave very low serum dilution values. However, when the slide testwas carried out at 37 C, it was negative in 9 of the 11 cases. In the remaining 2instances, one patient had a Forssman type of antibody which gave a 1:64 titer insaline and the slide test was positive at 37 C. In the other case no studies were madeon the effect of temperature and the nature of the agglutination reaction wasunfortunately not determined.

Using human and bovine albumen, sheep serum and human AB serum absorbedwith sheep cells as a diluent no evidence for blocking or hyperimmune antibodywas discovered in the cases of infectious mononucleosis studied in this series.Moreover, of the 6 patients with negative serology but with strong clinical andhematological evidence for the disease, no blocking or hyperimmune antibodywas disclosed by the slide test or by the use of absorbed human AB serum. Theconclusion seems justified that blocking, incomplete or hyperimmune heterophileantibody must be rather uncommon in infectious mononucleosis.

In the use of the rapid slide test it has been pointed out that cold agglutinins,(which may be abolished by warming to 37 C) and Forssman antibodies (whichmay be absorbed by guinea pig kidney) can give positive results. However, diseases in which cold agglutinins are strong enough to give a positive slide testare relatively rare and the occurrence of Forssman antibodies of a strength likely togive a positive slide test would be decidedly uncommon. In any event unless furtherexperience reveals more serious discrepancies, the rapid slide test as described inthis paper seems to offer a practical screening test to detect clinically significantamounts of heterophile antibody in cases of infectious mononucleosis.

     

Significance of granulomas in bone marrow: a study of 40 cases

Granulomas in bone marrow are an infrequent finding related to diverse disease. We reviewed 8057 bone marrow studies made over a period of 10.5 years, confirming the presence of granulomas in 40 patients. Global incidence was 0.50% and annual incidence 3.80 cases/yr. Because of the non-specificity of the morphological data, the diagnostic significance of the finding is limited, but it does serve to narrow the field of etiological possibilities. Associated disease was demonstrated in 82.5%, infectious diseases being the most common (tuberculosis, brucellosis, typhoid fever and kala-azar). Two previously unpublished entities are introduced: refractory anemia with excess blast cells (dysmyelopoietic syndrome) and malignant histiocytosis. 3 patients presented human immunodeficiency virus infection, the etiopathogenic role of this retrovirus in the generation of granulomas being unknown. The efficacy of bone marrow study in demonstrating granulomas increases if both the aspirate clot and bone cylinder are examined.