PMC9605839_01
(a) The peripheral blood showed increased nucleated red blood cells with signs of dysplasia (100x objective), (b) the aspirate smears showed profound dyserythropoeisis (50x objective), (c) aspirate smears also revealed readily identifiable hemophagocytic cells, consistent with hernophagocytic lymphohistiocytosis (50x objective).
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Review of the peripheral blood smear revealed numerous nucleated RBCs, a large subset of which exhibited signs of dysplasia, with abnormal nuclear contours, nuclear budding, and karyorrhexis (Figure 1(a)). The bone marrow aspirates showed a markedly decreased myeloid: erythroid ratio (0.3) and red cell precursors demonstrated profound dysplasia (>50% of cells) including multinucleate forms, nuclear budding, dysmaturation, and karyorrhexis (Figure 1(b)). Given the profound dyserythropoeisis, the initial impression was that this was consistent with a myelodysplastic syndrome, however, on further review of the smears, numerous hemophagocytic histiocytes were identified raising concern for hemophagocytic lymphohistiocytosis (HLH) (Figure 1(c)).