|Year : 2021 | Volume
| Issue : 1 | Page : 43-51
Utility of Bone Marrow Examination in the Diagnosis of Splenomegaly: Experience from a Tertiary Care Center
Vijay Kumar, Preeti Singh, Sunayana Misra, Sadhna Marwah, Garima Baweja
Department of Pathology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
|Date of Submission||24-Nov-2020|
|Date of Acceptance||02-Apr-2021|
|Date of Web Publication||28-Apr-2021|
MD, DNB Preeti Singh
Senior Resident, Department of Pathology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, Room no. 310, 3rd floor, OPD Building, Department of Pathology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: Establishing the diagnosis of splenomegaly is a clinical and pathological conundrum. The present study aimed to evaluate the clinicohematological findings and the significance of bone marrow examination in establishing the etiology of splenomegaly. Materials and Methods: This study was a retrospective analysis of patients with splenomegaly who had indications for bone marrow examination. The study was conducted over a period of 2 years. Detailed hematological and serological investigations were analyzed in those patients. Results: There were 96 males and 60 females. Most of the patients presented with fever. A mild degree of splenomegaly was found in 56.4% of the patients, followed by moderate (39.7%), and massive (3.9%) degree of splenomegaly. Pancytopenia was noted in 15.4% of the patients. Anemia was observed in 96.2% of the cases. Erythroid hyperplasia was the most common bone marrow finding (37.2%). Etiologies of splenomegaly were documented by the clinico-laboratory evaluation in 45.5% of the patients. Bone marrow examination along with peripheral blood examination alone established etiologies in 15.4% of the patients. Conclusion: Anemia and hematological malignancies formed a major part of the etiologies of splenomegaly. Bone marrow examination was an inevitable investigation in these situations. Serological investigations were useful in the diagnosis of nutrition deficiency anemia and infectious etiology. The grade of splenomegaly assessed clinically at the time of presentation provided an important clue for the etiology. Bone marrow examination proved to be an important diagnostic tool in the workup of patients with splenomegaly.
Keywords: Bone marrow examination, hematological investigation, serological investigation, splenomegaly
|How to cite this article:|
Kumar V, Singh P, Misra S, Marwah S, Baweja G. Utility of Bone Marrow Examination in the Diagnosis of Splenomegaly: Experience from a Tertiary Care Center. MAMC J Med Sci 2021;7:43-51
|How to cite this URL:|
Kumar V, Singh P, Misra S, Marwah S, Baweja G. Utility of Bone Marrow Examination in the Diagnosis of Splenomegaly: Experience from a Tertiary Care Center. MAMC J Med Sci [serial online] 2021 [cited 2021 Oct 24];7:43-51. Available from: https://www.mamcjms.in/text.asp?2021/7/1/43/314877
| Introduction|| |
The spleen is a distinct hematolymphoid organ, and its major functions involve the filtration of blood and maintenance of immune homeostasis. It is located in the left hypochondrium between the diaphragm and fundus of the stomach beneath the ninth, 10th, and 11th ribs. The spleen in a normal adult is usually not palpable. Historically, the spleen was thought to be a counterpart of the liver on the left side, despite the contrasting difference of their sizes. In fact, an abnormal enlargement of the spleen by weight or size is designated as splenomegaly. It could be the major or presenting symptom for a large spectrum of diseases.
Pathophysiological mechanisms of splenomegaly are diverse comprising congestive, infiltrative, immune, and neoplastic processes. Splenomegaly can be graded according to the degree of enlargement and the etiology varies with the different grades. Detection of splenomegaly on general physical examination and knowing the differential diagnoses of splenomegaly can facilitate the timely diagnosis and treatment of several conditions. The diagnosis of the exact etiology of splenomegaly demands a systematic approach. With this background, the present study aimed to analyze the clinicohematological findings across the various grades of splenomegaly and to evaluate the significance of bone marrow examination in establishing the etiology of splenomegaly.
| Materials and Methods|| |
This was a retrospective study conducted on patients admitted to a tertiary care hospital in the northern part of India over a period of 2 years (between January 2017 and December 2018). Patients admitted in medical wards with palpable spleen on per abdominal examination or spleen size >13 cm on ultrasound were regarded as having splenomegaly. Among the patients with splenomegaly, those who had hematological indications for bone marrow examination were included in this study. Patients without informed consent and adequate clinical information were excluded from the study. Institutional ethics committee approval was not necessary for the present retrospective study and hence not obtained. A total of 156 patients matched our inclusion criteria. Grading of splenomegaly was done by Hackett grading system. A palpable spleen more than halfway to the umbilicus, but not below a line running horizontally through the umbilicus were classified as moderate. A palpable spleen less than that of moderate were classified as mild and more than that of moderate were classified as massive.
Details of investigations like complete hemogram, peripheral blood smear findings, liver and renal function tests, iron profile, serum vitamin B12, and serum folate assay were retrieved from the medical records. Test results for hemolysis such as sickling test, osmotic fragility test, Lactate Dehydrogenase (LDH), and glucose-6-phosphate dehydrogenase (G6PD) were made available wherever indicated. Serological tests to rule out infectious etiologies such as human immunodeficiency virus (HIV), hepatotropic viruses, typhoid, dengue, malaria, leptospirosis, tuberculosis, and leishmaniasis were also noted in suspected cases.
Anemia was graded as mild, moderate, and severe, according to the World Health Organisation (WHO) recommendation. Hemoglobin level <8 g/dL was classified as severe, 8 to 10.9 g/dL was classified as moderate, and 11 to 11.9 g/dL was classified as a mild degree of anemia. An appropriate hemoglobin level was used for children <5 years of age. Total leukocyte count (TLC) >11,000/μL was considered as leukocytosis and TLC <4000/μL was considered as leukopenia. Platelet count <150,000/μL was considered as thrombocytopenia and platelet count of >450,000/μL was considered as thrombocytosis. The patients were classified to have pancytopenia if hemoglobin was <9 g/dL, TLC was <4000/μL and platelet count was <100,000/μL. The patients were classified to have hypersplenism if there was cellular bone marrow picture along with the presence of anemia, neutropenia, and thrombocytopenia either singly or in combinations.
| Results|| |
Among the 156 patients, there were 96 males and 60 females, with male to female ratio of 1.6:1. The age at the time of presentation to the hospital varied from 10 months to 90 years; the predominant proportion being between 11 and 20 years of age (21.2%). Duration of presenting complaints varied from 2 days to 6 years (mean − 3 months). The most common complaint at the time of presentation was fever (n = 91, 58.3%) followed by generalized weakness (n = 24, 15.4%). Other symptoms were abdominal pain, abdominal distention, breathlessness, yellow discoloration of the skin, and weight loss. Overlapping of these clinical presentations was also noted. Hepatomegaly was observed in 77 (49.3%) patients while generalized lymphadenopathy (bilateral cervical, axillary, and inguinal) was observed in only one patient (1.8%). The grade of splenomegaly was found to be mild in 88 (56.4%), moderate in 62 (39.7%), and massive in six (3.9%) patients.
Hemogram and biochemical findings
The various hemogram and biochemical investigations performed among the different grades of splenomegaly are summarized in [Table 1]. Hemogram revealed severe anemia in 61.8%, 50%, and 57.9% of patients with mild, moderate, and massive splenomegaly, respectively. Details of the number of patients with various grades of splenomegaly and their hemoglobin levels are illustrated in [Figure 1]. Severe anemia (n = 89, 57.1%) accounted for the predominant proportion of anemia, followed by moderate (n = 51, 32.7%), and mild (n = 10, 6.4%) anemia. Hemoglobin of ≥12 g/dL was noted in only 3.8% (n = 6) of the cases. Pancytopenia was noted in 15.4% of the patients, of which 10 had mild, 12 had moderate, and two had massive splenomegaly. Hypersplenism was present in 87.2% of the patients. Of these patients, 44.1%, 31.6%, and 24.3% had mild, moderate, and massive splenomegaly, respectively.
|Figure 1 Details of hemoglobin levels across the various grades of splenomegaly|
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The peripheral smear findings among the various grades of splenomegaly are illustrated in [Figure 2]. Normocytic normochromic picture (37.2%) was the most frequent type of red blood cell (RBC) morphology, followed by microcytic hypochromic (31.4%), dimorphic (21.8%), and macrocytic picture (9.6%). Anisopoikilocytosis was noted in 54 (34.6%) patients, ranging from mild (n = 25), moderate (n = 16), to marked (n = 3) degree. Tear drop cell was the most common (n = 29) poikilocyte observed in the peripheral blood smear, followed by elliptocyte (n = 19), ovalocyte (n = 16), target cell (n = 8), macroovalocyte (n = 5), spherocyte (n = 4), and pencil cell (n = 2). Leukopenia was noted in 43.6% while leukocytosis was noted in 18.6% of the patients. Thrombocytopenia was noted in 54.5% whereas thrombocytosis was noted in only 2.6% of the patients.
|Figure 2 Details of peripheral smear findings across the various grades of splenomegaly|
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Erythroid hyperplasia was the most common bone marrow finding (n = 58, 37.2%) noted in the present study, with a predominant proportion being normoblastic erythroid hyperplasia (n = 29, 50%). Megaloblastic erythroid hyperplasia was noted in 18 (31%) patients [Figure 3]A. Dyserythropoiesis was noted in 32 (20.5%) patients. Reactive changes without any specific morphologically identifiable etiologies were noted in 49 (31.4%) patients. Six of these cases had hemophagocytosis. Normal bone marrow findings were noted in 24 (15.4%) patients. Details of bone marrow findings across the various grades of splenomegaly are illustrated in [Figure 4].
|Figure 3 (A) Bone marrow aspirate smears showing megaloblasts (Giemsa, 1000×). (B) Bone marrow aspirate smear of acute myeloid leukemia showing numerous myeloblasts (Giemsa, 400×). (C) Peripheral blood smear of chronic myeloid leukemia showing leukocytosis with all stages of myeloid cells, eosinophils (black arrow) and basophils (blue arrowhead) (Giemsa, 1000×)|
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|Figure 4 Details of bone marrow findings across the various grades of splenomegaly|
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Etiologies of splenomegaly
Etiologies of splenomegaly were documented by the clinico-laboratory evaluation in 71 (45.5%) patients. They were classified as hematological, infective, and congestive categories. Hematological causes (n = 55, 77.5%) accounted for most of these etiologies. Among the nonneoplastic hematological causes, 14 cases were diagnosed as megaloblastic anemia, 16 patients as iron deficiency anemia, seven patients as hemolytic anemia, and one patient of sickle cell disease. Among the neoplastic hematological causes, there were six patients of acute lymphoblastic leukemia, three patients of acute myeloid leukemia [Figure 3]B, four patients of chronic myeloid leukemia [Figure 3]C, two patients of mature B cell neoplasm [Figure 5]A, and one patient of primary myelofibrosis and juvenile myelomonocytic leukemia each. Typhoid (n = 2), tuberculosis (n = 1), leishmaniasis (n = 5) [Figure 5]B, malaria (Plasmodium vivax, n = 1) [Figure 5]C, human immunodeficiency virus (n = 1), chikungunya (n = 1), and combined hepatitis B and C virus infections (n = 1) were identified among the infectious etiologies. Congestive splenomegaly was found in three of the patients with portal hypertension resulting from chronic liver disease. There was one case of storage disorder (Gaucher disease) among the miscellaneous category.
|Figure 5 (A) Bone marrow biopsy showing a nodular pattern of infiltration by lymphoid cells, NHL (H&E, 200×) (inset − IHC, CD20-positive B cells). (B) Bone marrow aspirate smears showing abundant extracellular (black arrow) and few intracellular (blue arrowhead) Leishmania donovani amastigote forms (Giemsa, 1000×). (C) Bone marrow biopsy showing increased histiocytes containing brown malarial pigment (H&E, 1000×). H&E, Hematoxylin and Eosin; IHC, Immunohistochemistry; NHL, Non-Hodgkin Lymphoma|
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In megaloblastic anemia, vitamin B12 ranged from 140 to 2000 (mean − 765) and folic acid level ranged from 0.9 to 20 (mean − 5.38). Macrocytic RBCs were noted in 11 (78.6%) patients with megaloblastic anemia. Iron levels in iron deficiency anemia ranged from three to 48 (mean − 22.3). Microcytic hypochromic RBCs were noted in 15 (93.8%) of the patients with iron deficiency anemia.
| Discussion|| |
In ancient times, the spleen was considered as an organ that secretes black bile (one of the four bodily humors). However, in the present time, it is one of the major organs involved in hematological and immunological functions. Splenic enlargement is an important sign of its dysfunction. An early description of splenic enlargement was documented by Philippe Charles Ernest Gaucher in 1855, in his thesis submitted for his doctorate in Medicine. We now know the disease in his name, which once remained as just a description. It took centuries to understand the functions and pathology of this complex organ, and still much needs to be explored.
Splenomegaly presents a diagnostic challenge because it is nearly always due to another primary disorder. Many techniques exist for detecting enlarged spleens on physical examination, but their sensitivity can be low, and they are limited by body habitus. Imaging studies such as ultrasound and Computed tomography (CT) are helpful modalities in the diagnosis of splenomegaly; however, may not point toward the etiology. As treatment depends on the underlying disease, a thorough evaluation of various etiologies of splenomegaly needs to be done, of which hematologic evaluation is a very vital component. The final diagnosis requires sharp clinical acumen along with the processing of the battery of investigations performed and must be strained out of the wide list of differentials.
The age range of the patients with splenomegaly in the present study (10 months–90 years) was comparable to the previous studies (0–91 years).,,, The mean age in the present study (31.7 years) was slightly lesser than the recorded mean age (52 years) by Curovic et al. This deviation might be due to the skewed age distribution toward the younger population in the present study and regional variations of the cohorts included. There was a slight male preponderance in the present study and similar gender distribution was noted in the previous reports.,,,
Fever was the most common presenting symptom (about 50%) in most of the previous studies,, as was seen in ours. According to the studies by Agarwal and Mittal and Tangde and Bindu, splenic enlargement of the mild degree was the predominant finding at the time of presentation, followed by moderate and massive enlargement. Similar results were observed in the present study with 56.4% of cases presented with mild splenomegaly. About 49% of the patients in the present study had associated hepatomegaly, which falls within the range (26%–73%) reported in the literature.,, This wide range of frequency might be due to the variation in the etiologies identified and the methods of detection of hepatomegaly.
Biochemical investigations like iron profile and vitamin B12 and folate levels were helpful in the diagnosis of iron deficiency and megaloblastic anemia, respectively. The liver function test, blood urea, and creatinine stood as supporting investigations.
In the present study, anemia was present in 96.2% of the patients, which is similar to the published data (98%) by Chandanwale et al. The predominant proportion of the patients had moderate to severe anemia (89.7%). A similar observation was also noted by Mandar and Meenal and Tangde and Bindu. The morphological size of RBCs seen in the present study was similar to the observations made by Dabadghao and Raskar, except for the higher percentage of dimorphic RBCs (21.8%) in the present study. However, in their study, they included cases of splenomegaly with or without bone marrow indication. The percentage of leukocytosis (18.6%) observed in this study was comparable with the result obtained by Tangde and Bindu (23.7%). In contrast, Agarwal and Mittal, in their study noted more cases with leukocytosis (44%). This might be explained by the fact that they had more cases with infectious etiology and hematological malignancy in their study. Thrombocytopenia and thrombocytosis were noted in 54.5% and 2.6% of the patients in the present study, respectively, which corresponded to those observed by Chandanwale et al. and Tangde and Bindu. Pancytopenia was noted in 15.4% of the patients in the present study. The element of hypersplenism was remarkably high in the present study (87%), in contrast to the studies by Mandar and Meenal (31.1%) and Agarwal and Mittal (8%). This disparity might be because the present study evaluated only those patients with bone marrow indication.
In the present study, only patients with expected bone marrow changes were included and about 15.4% (n = 24) of the patients showed no significant morphological changes. About 37.7% of the diagnosis was established using bone marrow examination alone. Bone marrow hyperplasia (erythroid and myeloid) was the most common bone marrow finding noted in 47.4% (n = 74) of the patients in the present study. Hematological conditions constituted a major portion (77.5%, n = 55) of the etiologies of splenomegaly in the present study. This was analogous (60%) to the observations noted by Chandanwale et al. and Bathija et al. Among the hematological conditions, nonneoplastic causes (69.1%) were more than neoplastic causes (30.9%) in the present study. Iron deficiency anemia accounted for about 10% of the cases which is lesser to the result obtained by Chandanwale et al. (18%). The possible explanation for this might be due to the difference in the prevalence of iron deficiency among the northern and western parts of India. Megaloblastic anemia constituted about 9% of the cases which is similar to that reported by Chandanwale et al.
Bone marrow examination along with peripheral blood examination alone in the present study revealed specific etiologies in 24 (15.4%) patients. These diagnoses were acute leukemia, myeloproliferative neoplasms, myeloproliferative/myelodysplastic neoplasms, mature lymphoid neoplasms, leishmaniasis, malaria, and storage disorders.
Bone marrow examination disclosed the pattern of bone marrow response and the corresponding morphological findings, thereby assisting in identifying the type of anemia. One should always keep in mind about the coexistence of multiple types of anemia and their morphological features. Bone marrow examination is also important for differentiating the hematological malignancies and myeloproliferative neoplasms from the nonneoplastic conditions. Massive splenomegaly was the usual presentation of chronic myeloid leukemia. A case of juvenile myelomonocytic leukemia noted in the present study also had massive splenomegaly. Bone marrow examination in these myeloproliferative/myelodysplastic neoplasms was of great help in deciding the specific molecular tests needed to establish the diagnosis. Morphological evidence of storage disorders is crucial, especially in resource-poor settings.
A detailed hematological workup was carried out in two cases of the mature B cell lymphomas found in this study. In the first case, the peripheral blood, bone marrow aspiration and biopsy, and immunophenotypic features (atypical lymphocytes with cytoplasmic processes; positive − CD19, CD20, CD79b; negative − CD5, CD10, CD23, CD103; kappa restriction) were found to be consistent with the diagnosis of splenic marginal zone lymphoma (SMZL) [Figure 6]A–D. In the second case, the peripheral blood and bone marrow aspiration and biopsy findings along with immunophenotypic features (positive − CD20; negative − CD5, CD10, CD23; lambda restriction) suggested a differential diagnosis of either SMZL or hairy cell leukemia. The hematological clues and immunophenotypic findings that can aid in appreciating the probable diagnosis and eliminating the clinical mimickers were discussed in a previous publication by Mohanpuria et al.
|Figure 6 (A) Peripheral blood smear of splenic marginal zone lymphoma showing atypical lymphocyte with cytoplasmic processes (villous lymphocytes) (Giemsa, 1000×). (B) Bone marrow biopsy showing abnormal infiltration by atypical lymphoid cells (H&E, 400×). (C) Immunostaining showing CD20 positive cells in an interstitial pattern of infiltration (IHC, 200×). (D) Immunostaining showing kappa light chain restriction (IHC, 400×). H&E, Hematoxylin and Eosin; IHC, Immunohistochemistry|
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Bone marrow aspirates with evident hemophagocytosis were carefully evaluated for hemophagocytic lymphohistiocytosis (HLH). Out of the six cases with hemophagocytosis, four cases fulfilled the criteria for HLH. Three of these cases were classified as secondary HLH, due to infections like tuberculosis, leishmaniasis, and typhoid. Bone marrow examination not only assisted in diagnosing HLH but also further recognized the secondary form. Kumar et al. in their study emphasized that HLH was an underdiagnosed entity and a high index of suspicion was necessary while examining the bone marrow with hemophagocytosis.
In the present study, infectious agents constituted a significant proportion (n = 12, 7.7%). Of these, the hematological examination alone could identify the etiologies in six patients (50%). Leishmaniasis was the most common etiology in this region of the country and a similar observation was reported in a study from the same region. Serological workup for bacterial, viral, or parasitic infections was useful in diagnosing infectious causes of splenomegaly. Bone marrow examination was diagnostic in identifying hemoparasites and leishmaniasis. The approach to bone marrow examination in patients with splenomegaly in the present study had been illustrated in the flow chart [Figure 7]. The diagnostic test used to establish the final diagnosis had been mentioned at the bottom of the flow chart.
|Figure 7 Flow diagram showing the approach used in bone marrow examination of the patients with splenomegaly|
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To conclude, splenomegaly was noted in a wide range of age, with slight male predilection and overlapping clinical features, thus demanding numerous investigations. A careful examination of peripheral blood and bone marrow samples proved to be an important diagnostic tool in the workup of patients with splenomegaly. However, many remained undiagnosed when only hematological investigations were analyzed. It should be noted that the final diagnosis involves a multidisciplinary approach. Anemia and hematological malignancies formed a major part of etiologies. Serological investigations were useful in the diagnosis of nutrition deficiency anemia and infectious etiology. Nutrition deficiency anemia constituted an appreciable portion of patients with splenomegaly and they can be easily treated. The grade of splenomegaly at the presentation provided an important clue for the etiology. This study reassured the importance of hematological workup in the evaluation of splenomegaly. A large study including more patients and involving multiple institutions might reveal statistically relevant information.
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