BONE MARROW NECROSIS IN SICKLE CELL DISEASE, A CLINICAL & PATHOLOGICAL STUDY

Bone marrow necrosis in sickle cell disease, a clinical & pathological study
Zuhair A.Al-Barazanchi
Basrah Journal
Of Surgery
Bas
J
Surg,
March,
13,
2007
BONE MARROW NECROSIS IN SICKLE CELL DISEASE,
A CLINICAL & PATHOLOGICAL STUDY
Zuhair A Al-Barazanchi*, Alwan H Al-Shiwaeli#
*M.Sc Haematol. Consultant Haematologist, Post-graduate Supervisor & Lecturer, Laboratory Department,
Basrah General Hospital. # M.Sc Haematol. Specialist Haematologist, Al-Faeha General Hospital.
Abstract
Bone marrow necrosis (BMN) is a rare clinical-pathological entity. It is mostly associated with
post-mortem changes. Ante-mortem existence of BMN is quite rare and usually indicates a poor
prognosis. However, its association with non-hematological malignancies seems not to be as
poor prognostic feature as in post-mortem changes. One of the most commonly disorders
associated with BMN is sickle cell disease (SCD), which is common among people in Basrah
province. The current study probably can put light on the incidence of such pathology among
those with SCD, its most clinical presenting features and its relation with specific sickle disease
genotypes. The incidence of BMN in this study was 4.9 %. The mostly encountered features with
wide spread necrosis were bone pains, fever, and pallor. Peripheral blood showed a florid leuco-
erythroblastic picture with reticulocytosis and leucopenia in another case with focal necrosis. On
comparison with those patients without BMN, patients with BMN showed a significantly lower Hb
concentration, higher Hb S concentration, lower Hb F concentration, smaller splenic size, higher
number of irreversibly-sickled cells and more frequent painful crises during their life. Those
results were compatible with some observations and contradict with other. However, there is no
previous study conducted in Iraq to compare with.
Introduction
dehydrogenase (LDH) enzyme7.
one marrow necrosis (BMN) is
Peripheral blood usually shows anemia,
Bconsidered to be present when the leuco-erythroblastosis, and schisto-
marrow aspirate and or biopsy show
cytosis8. Marrow aspirate shows
areas of poorly defined (smudge) cells
amorphous material with isolated cells in
with basophilic indistinct nuclei
different stages of necrobiosis and
surrounded by amorphous to granular
variable degrees of pancytopenia9.
acidophilic material1,2.
Clinically it usually presents as severe
It was described for the first time more
bone pains, fever, and weight loss8. It is
than 50 years ago3. It is characterized
seen in association with haematological
morphologically by destruction of
malignancies, like acute & chronic
normal haemopoietic tissue including the
leukemia, malignant lymphomas, and
stroma with the preservation of the
multiple myeloma5, in metastatic
bone4. It is a rare entity, most frequently
neoplasia, and bacterial infections
associated with post-mortem changes5
especially when hypovolemia and septic
appearing in up to 19.8 % of all
shock are present. It can also be
autopsies4. Severe necrosis of the
encountered with disseminated
marrow is infrequently diagnosed during
intravascular coagulation, and following
life and its presence often indicates a
irradiation, and anti-neoplasic therapy.
poor prognosis5. BMN ranges from a
Rare cases had been reported in
localized to wide spread generalized
association with antiphospholipid
process6. It is usually accompanied by
syndrome10,11, and parvovirus B1
hypercalcemia and elevation of lactate
infections preceding the development of
Bas J Surg, March, 13, 2007

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Bone marrow necrosis in sickle cell disease, a clinical & pathological study
Zuhair A.Al-Barazanchi
hematological malignancies. BMN can
each patient. Bone marrow aspiration
also be associated with sickle cell
had been performed by the standardized
disease6,12. Its prognosis is not so poor
Salah BM needle from the right and or
when associated with sickle cell disease
left posterior iliac spines using the
and other non-malignant states6.
standardized procedure after full aseptic
precautions and ample local anesthesia.
Materials & methods
Smears were stained by the Leishmann’s
During a period of one year, 41 adult
stain & one smear was stained by
cases with various forms of sickle cell
Prussian blue stain to study iron status of
disease, from 4 Central Hospitals in
the marrow13.
Basrah, were studied. Sickle cell trait
Bone marrow trephine biopsy was
cases were excluded.
performed to each patient at the same
The study included a full history taking,
session of marrow aspiratin, using the
including gender, age, residency,
standardized Jamshidi needle from the
presence or absence of painful crises and
right or left posterior iliac crest13. A core
their frequency, history of blood
of bone & marrow material 1.5 cms long
transfusion and its frequency and any
x 2 mm diameter was taken & touch
other complaint related to their illness
smears were done & stained after drying
during their life. All cases were
with Laishmann’s stain while biopsy
subjected to thorough physical
materials were processed in paraffin
examination, concentrating on height,
sections using the standard paraffin
body weight, the presence or absence of
embedding & sectioning technique13.
pallor, jaundice, bone tenderness, fever,
Eosin & hematoxylin-stained sections
hepatomegaly & splenomegaly (the sizes
were prepared & examined.
of the latter two were estimated
Statistical analysis was performed using
clinically as fingers below the costal
the SPSS 12 version, by obtaining the
margin). Patients who did receive blood
descriptive values & the 2 x 2 Chi square
one month & less before & those who
test & the student t test.
were on hyroxyurea therapy were
excluded from the study.
Results
All cases were subjected to peripheral
Two cases (4.9 %) had been shown to
blood examination, including a full
have bone marrow necrosis at the time of
blood count using the MS9 machine,
examination, while 39(95.1%) had not.
blood film examination for cell
(Table III).
morphology, sickling phenomenon,
first case was a female with extensive
reticulocyte counting with correction,
marrow necrosis with almost total loss of
enumeration of irreversibly sickled cells,
normal cellular elements, and
and performing Hb variant study, using
replacement by homogeneous
the Bio-Rad Hb variant system/B-thal
amorphous material seen in aspirate
short Program (by the HPLC principle)
(Figure 1) while the H & E BM trephine
after application of the standardized
biopsy showed a homogeneous
techniques13
and taking into
acidophilic material with loss of cellular
consideration manufacturers instructions.
details (Figure 2). She was 35 years old,
Cases were genotyped according to
with blood group A Rh (D) positive. She
references13-15(Tables I & II).
presented with severe bone pains,

All cases were subjected to bone
running fever, and pallor. On
marrow examination after a full
examination she was frankly pale, there
explanation of the procedure had been
was no splenomegaly, nor hepato-
done to each patient followed by
megaly. Her Hb concentration was 68
obtaining a written legal agreement of
g/L, Hb variant study showed Hb S
Bas J Surg, March, 13, 2007

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Bone marrow necrosis in sickle cell disease, a clinical & pathological study
Zuhair A.Al-Barazanchi
(82.7%), Hb F 7.7 % (Figure 3). She had
(16 %). ISCs were 0.2 %. Her skeletal
a rapid sedimentation rate (145 mm/ 1st
X-ray screen showed osteonecrosis of
hr). The WBC count was 13.7 x 109/L
hip bones. Her genotype was sickle-B+
with leuco-erythroblastic blood picture.
thalassaemia (Hb S/B+ thal).
She had a low MCV with reticulocytosis
Figure 1: BM aspirate smear stained by Leishman,s stain shows total distortion of normal
cellular details with replacement by amorphous basophilic material.
Figure 2: Bone marrow trephine biopsy section, stained with H & E from the first case
shows complete destruction of normal cellular marrow elements with replacement by
homogeneous acidophilic material.
Figure 3: HPLC paper of the first case of BMN.
Bas J Surg, March, 13, 2007

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Bone marrow necrosis in sickle cell disease, a clinical & pathological study
Zuhair A.Al-Barazanchi
The second case was an 18 years old
hepatomegaly. Hb S was 81.3 %, Hb F
male who showed focal areas of necrosis
16.1 %,. He had leucopenia, Hb 48 g/L,
in both right & left posterior iliac crest
reticulocytes count 4 %& ISCs 1.5 %.
bones (Figure 4). His blood group was O
He had a moderately elevated ESR but
Rh (D) positive, he presented with
no leuco-erythroblastic blood picture.
severe bone pains, running fever, &
His genotype was sickle/Bo thalassaemia
pallor. He has splenomegaly but no
(Hb S/Bo thal)(Table IV).
Figure 4: H & E section of the bone marrow of second case shows destruction of normal
cellular elements with replacement by amorphous, homogeneous acidophilic material.
Few normal cellular elements are seen as well.
Comparative study between cases with
following parameters : Hb concentration,
bmn & those without:
the number of painful crises the patient
Cases with BMN had lower hemoglobin
had suffered during life, body weight,
concentration (mean 58), than those
MCH, & monocyte count (P< 0.05),
without, higher Hb S concentration
while it showed no significant relation
(mean 82 % vs 74.8 %), lower Hb F
with other parameters using the t-Test
concentration (mean 12.9 % vs 14.6 %)
(Table VI). Besides, BMN showed a
& smaller splenic size (mean 1.5 CBCM
significant correlation with fever, bone
vs 4.2) (Tables IV,V).
pains (P <0.05) & highly significance
Bone marrow necrosis was found to
(P<0.01) with osteonecrosis using the
have a significant relationship with the
Chi square test (Table VII).
Discussion
stated for BMN6, yet bone marrow
In our study, 2 cases (4.9%) showed the
trephine biopsies taken from both right
histological features compatible with
and left posterior iliac crests showed
bone marrow necrosis while the rest (39,
focal areas of necrosis. On reviewing the
95.1 %) didn't show such features. Only
literature, very little had been found to
one case, a female 35 years old, showed
compare with.
the florid clinical and hematological
It seems that the first description of
features of bone marrow necrosis (severe
BMN in 1941 in a Greek woman with
bone pains, fever, pallor, rapid
splenomegaly and sickled red blood cells
sedmintation rate, leuco-erythroblastosis
in peripheral blood who died of cerebral
and features of necrosis). She was of
fat embolism16.However, Charache-S
sickle-B+ thalassaemia type. However,
and Page17 reported 3 cases with sickle
the second case didn't show the classical
cell disease with BMN. Hemoglobin
clinical and haematological features
electrophoresis showed Hb SC, SD & SS
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Bone marrow necrosis in sickle cell disease, a clinical & pathological study
Zuhair A.Al-Barazanchi
with an incidence of 6.8 %. It seemed
worked on ante-partum diagnosed cases
that BMN was more common among
with extensive BMN and found that
those with Hb SC (50%) seen at autopsy
bone pains, fever, were the most
rather than those with Hb SS disease
important symptoms followed by
(17%) and this had been attributed to the
anemia, thrombocytopenia and leuco-
potentially high viscosity of blood in Hb
erythroblastic picture3. Our incidence of
SC due to the relatively high haematocrit
BMN (4 %) seems much less than that
in such disorder17. However, Al-Gwaiz,
reported by Maisel etal, 198819, who
1997, in her retrospective study showed
classified the BMN into 3 grades: grade
that no case of sickle cell disease with
1 (only small foci of necrosis), grade II(
BMN had been found18. To our
moderate necrosis) & grade III (severe
knowledge, no prospective study had
wide spread necrosis) and found an
been previously conducted in Iraq to
incidence of ( 26.4 %, 7.5 %, and 3.1 %
compare with. The paucity of
for each of above grades respectively).
descriptions probably doesn't reflect a
This is attributed to the inclusion of wide
low incidence but rather a little chance to
range of other causes of BMN (rather
examine the marrow by such an invasive
than SCD) in their study19. However, the
marrow biopsy procedure during the
lack of facilities to diagnose the
painful crises of sickle cell-diseased
association of parvovirus B19 infection
patients as well as the unwilling of the
with sickle cell disease (using the
patients and treating physicians to
polymerase chain reaction) in the
perform such an unnecessary
pathogenesis of wide spread BMN seems
investigation17,18. Our clinical findings in
to lead to an under-estimation of such
the first female case with widespread
process in SCD patients in our
necrosis were compatible with those
Country20,21.
described by Janssen et al, 2000, who
Table I: Genotyping of patients with sickle cell disease13.
Genotype
MCV
S%
A%
A2%
F%
SS
N
88-93
0
<3.5
5-10
S/Bothal
L
88-93
0
>3.5
5-10
S/B+thal
L
50-93
3-30
>3.5
1-10
S/HPFH
N
65-80
0
<3.5 20-35
Table II:Genotyping of patients with sickle cell disease14,15*
Genotype
Cell.
Acetate
Hb
Hb F Hb A2 Hb A
Hb S
Hb
MCV
Cor.
electrophoresis
(%)
(%)
(%)
(g/L)
(fl)
Retics
(%)
Hb
SS
S(+F)
1-20
2-4 0 75-95
78
85.9
10.2
(4.6*)
Hb S/BoThal S+F
5-30
4-8
0 70-90
89
69.3
7.2
(5.2*) (5*)
Hb S/B+Thal S+F+A
2-10 4-8 10-30
60-85
89-116 64-73
1.3-9.7
Hb S/HPFH S+F
15-35
1.5-3
0 60-90
146 81.7 2.4
(25.8*) (2*)
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Bone marrow necrosis in sickle cell disease, a clinical & pathological study
Zuhair A.Al-Barazanchi
Table III: shows the frequency of BMN in cases under the study
BMN No %
Present 2 4.9
Absent 39 95.1
Table IV: A comparison between the two cases of BMN
Variables
Case 1
Case 2
Age (Years)
35
18
Duration of illness
15
10
Blood group
A
Rh(D)
+
O
Rh(D)
+
Crises/Life
10
10
Blood transfusion/Life
40
1
Liver size(cbcm)
0
0
Splenic size(cbcm)
0
3
Hb (g/L)
68
48
ESR(mm/1st hr)
145
62
Hb S %
82.7
81.2
Hb F %
7.7
16.1
ISCs %
0.2
1.5
tWBC
13.7
1.8
Cor. Retics %
16
4
MCV(fl)
67.4
62
Blood
film
Leuco-erythroblastic Leucopenia
Osteonecrosis
Positive
Negative
Genotype
S/B+ thal
S/Bo thal
Iron stores in Marrow
Normal
Normal
Extent of BMN
Extensive
Focal
Table V:Comparative study between those without & others with BMN.
Patients without BMN
Patients with BMN
Variable
Mean (SD)
Mean (SD)
Age(Years)
19.6 (4.3)
26.5 (12)
Duration of illness(Years)
4.3 (3.5)
12.5 (3.5)
Painful crise/Life
22.4 (12.9)
10 (0)
Blood transfusion/Life
9.8 (8.3)
20.5 (27.5)
Splenic size(cbcm)
4.2 (4.2)
1.5 (2.1)
Hb(g/L)
95 (21)
58 (14)
WBCs
21.5 (17.5)
7.7 (8.4)
Corr. Retics(%)
4.5 (4.5)
10 (0.8)
ESR(mm/1st hr)
18.3 (21.5)
103 (58)
MCV(fl)
77.4 (10.9)
64.7 (3.8)
MCH(pg)
25.4 (5)
16.9 (0.8)
MCHC(g/dl)
31.5 (3)
26.1 (0.2)
Neutrophils(x109/L)
4.9 (12.2)
4.3 (11.3)
Lymphocytes(x109/L)
4.4 (10.7)
5.2 (1.4)
Monocytes(x109/L)
6.0 (7.1)
4.6 (2.2)
Hb A(%)
5.6 (7.4)
3.4 (4.8)
Hb A2(%)
4.2 (1.9)
5.3 (3.8)
Hb F(%)
14.6 (8.3)
12.2 (7.3)
Hb S(%)
74.8 (7.9)
82 (0.9)*
ISCs(%)
1.9 (2.1)
0.8 (0.9)
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Bone marrow necrosis in sickle cell disease, a clinical & pathological study
Zuhair A.Al-Barazanchi
Table VI: BMN correlation ( quantitative parameters)
St error
Variable
t
df Sig.(2-tailed) Mean
difference
difference
Age(Yrs)
2.017
39 >0.05
6.83
3.38
Duration
of
illness 3.21 39
<0.01
8.19
2.54
No.
of
crises/Life -2.06 39
<0.05
-0.69
0.33
Splenic
size(cbcm) -.907 39
>0.05
-2.75
3.04
Liver
size(cbcm) -1.281 39
>0.05
-2.4
1.94
Weight(kg) -2.214
39 <0.05
-22.4
10.12
Height(cm) 1.04
39 >0.05
9.35
8.94
ESR(mm/1st
hr) 5.05 39
<0.01
85.1
16.8
Hb(g/L)
-2.402
39 <0.05
-3.77
-0.59
MCH(pg)
-2.376
39 <0.05
-8.56
3.60
MCHC(g/L) -2.467
39 <0.05
-5.43
2.20
MCV(fl)
-1.632
39 >0.05
-12.76
7.82
Hb
A(%)
-0.414
39 >0.05
-2.2
5.32
Hb
A2(%)
0.749
39 >0.05
1.10
1.47
Hb
F(%)
-.294
39 >0.05
-1.78
6.07
HbS(%)
1.256
39 >0.05
7.105
5.65
ISCs(%)
-0.708
39 >0.05
-1.11
1.57
WBCs(x109/L) -0.378
39 >0.05
-4.77
12.62
Lymphocytes(x109/L)
0.097
39 >0.05
7.505
7.80
Monocytes(x109/L) -.285
39 >0.05
-1.5
5.27
Neutrophils(x109/L) -0.726
39
>0.05
-6.4
8.94
Cor.Retics(%) 1.608
39 >0.05
5.48
12.38
Table VII: BMN correlations (qualitative parameters)
Variable
Chi-Square
df
Sig.(2-sided)
Blood group
1.726 3 >0.05
Bone pains
0.510 1 <0.05
Erythroid
hyperplasia 4.529 1
>0.05
Fever
5.734 1 <0.05
Gall stones
0.292 1 >0.05
Hypercellular
BM
4.529 1 >0.05
RBC
normochromia 0.632 1 >0.05
Osteonecrosis
9.226 1 <0.01
Sex
2.806 1 >0.05
Bas J Surg, March, 13, 2007

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Bone marrow necrosis in sickle cell disease, a clinical & pathological study
Zuhair A.Al-Barazanchi
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