PMC6069324_01
(a) Ultrasonography abdomen showing omental caking and peritoneal thickening. (b) Computed tomography image revealing ascites, hepatosplenomegaly, and thickened peritoneum. (c) Contrast-enhanced computed tomography image shows ascites, bilateral pleural, and mild pericardial effusion
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F1
Ultrasound of the abdomen revealed hepatosplenomegaly and gross ascites with omental caking and peritoneal thickening which was suggestive of tubercular etiology keeping in with the high incidence of tuberculosis in India [Figure 1a]. Gross ascites along with thickened peritoneum were also noted [Figure 1b]. Moderate pericardial effusion was also found [Figure 1c].
(a) Cellular smear showing numerous myeloid cells in various stages of maturation, occasional group of erythroid cells (red arrow), and scattered megakaryocytes (Giemsa, x200). (b) Large multinucleated and multilobulated megakaryocytes (Pap, x400). (c) Cell block section revealing scattered megakaryocytes along with numerous myeloid series cells (H and E, x200). (d) Bone marrow biopsy shows markedly hypocellular marrow with diffuse fibrosis of marrow spaces (H and E, x200). Inset shows megakaryocytes. (e) Fibrotic areas show increase in reticulin with extensive intersection (reticulin, x200). (f) Masson's trichrome stain showing diffuse blue-stained coarse bundles of collagen (MT, x200)
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F2
Smears were highly cellular and revealed all the three lineages of hematopoietic cells with a predominance of myeloid series cells which were seen in all stages of maturation along with occasional cells of erythroid series and many megakaryocytes [Figure 2a]. The morphology of megakaryocytes was clearer in Papanicolaou-stained smears revealing multiple distinct nuclei [Figure 2b]. Cell block was prepared from the peritoneal fluid which also showed evidence of EMH [Figure 2c]. However, bone marrow biopsy showed markedly hypocellular marrow with diffuse fibrosis of marrow spaces and focal vascular proliferation [Figure 2d]. Few megakaryocytes were seen [Figure 2d; inset]. Reticulin stain showed diffuse and dense increase in reticulin with extensive intersection [Figure 2e]. Coarse bundles of collagen were seen diffusely staining blue on Masson's trichrome stain [Figure 2f].