PMC5726878_01
(a): Bone Marrow Aspirate (H&E X 100) shows the presence of lymphoblasts (arrows), consistent with ALL. (b): Bone Marrow Trephine (H&E X 100) shows the persistence of lymphoblasts, highlighted with TDT staining (arrow), post-induction chemotherapy
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Bone marrow aspirate and trephine showed a hypercellular marrow with decreased tri-lineage hematopoiesis and 90% blasts [Fig. 1(a)]. Bone marrow assessment after phase-1 of 4-drug induction chemotherapy revealed the persistence of 13% blasts by flow cytometry and 15% on trephine [Fig. 1(b)].
(a & b): Bone Marrow Trephine shows pleomorphic histiocytes (arrows), consistent with Secondary Malignant Histiocytosis
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In view of his persistent fever, a mid-cycle bone marrow aspirate and trephine were performed which showed a reduction in lymphoblasts to 5% by flow cytometry and an extensive infiltration of malignant histiocytes, amounting to nearly 80%, with no associated hemophagocytosis [Figs. 2(a) & (b); 3(a) & (b)].
(a & b): Bone Marrow shows histiocytosis on immunohistochemistry (IHC): Bone Marrow Trephine shows immunostaining for CD4 (X200) [a] and PGM1 (X200) [b], indicative of histiocytic infiltration.
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In view of his persistent fever, a mid-cycle bone marrow aspirate and trephine were performed which showed a reduction in lymphoblasts to 5% by flow cytometry and an extensive infiltration of malignant histiocytes, amounting to nearly 80%, with no associated hemophagocytosis [Figs. 2(a) & (b); 3(a) & (b)].
Bone Marrow Trephine, post-allogeneic transplantation, shows trilineage hematopoiesis with the absence of lymphoblasts and histiocytes.
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His bone marrow examination, 70 days' post-allogeneic stem cell transplantation, showed a complete morphological [Fig. 4], flow cytometric and cytogenetic remission.