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Microscopic images of the bone marrow biopsy. (A) low-power magnification of May-Grunwald/Giemsa stain showing hypocellular marrow with a lymphoid germinal center. (B) high-power view demonstrating decreased hematopoiesis with interspersed lymphocytes. CD3, CD20: immunohistochemical stains highlighting mixed, polyclonal nature of T and B-lymphocytes in the tissue.
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Bone marrow biopsy demonstrated severely hypocellular marrow with polyclonal lymphoid aggregates and normal karyotype, consistent with severe aplastic anemia (Fig. 1).
Images of the cardiac magnetic resonance imaging (MRI) and 2D echocardiogram sequence visualizing the intraventricular thrombus. (A) MRI, coronal projection, inversion-recovery fast low-angle shot sequence (FLASH). (B) MRI, four-chamber axial image from the steady-state free-precession sequence. (C) Echo, two-chamber apical window showing a homogenous echodensity in the apex. (D) four-chamber apical window. (E) short axis parasternal view.
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Further investigation with a 2D echocardiogram, cardiac catheterization and MRI (Fig. 2) confirmed a 3.4 cm tethered, mobile intraventricular mass and no cardiac function abnormality.
CD59 red cell flow cytometry histogram at the initial presentation and at the time of thrombus diagnosis, when a bimodal distribution with a dominant PNH clone became manifest.
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CD55/59 flow cytometry confirmed a new diagnosis of paroxysmal nocturnal hemoglobinuria (PNH), with over 80% CD55/59-deficient red cells and granulocytes (Fig. 3). Continued anticoagulation was prescribed.
Tracing of the patient's cytopenias (platelets:green, haemoglobin:red, neutrophil count:blue) on the backdrop of the clinical events.
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Figure 4 tracks the history of the patient's cytopenias on the background of clinical events.