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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 41  |  Issue : 1  |  Page : 23-26

Haematological indices and bone marrow morphology in pancytopenia/bicytopenia


Department of Pathology, Dr P.D.M. Medical College, Amravati, Maharashtra, India

Date of Submission30-Apr-2015
Date of Acceptance23-Jun-2015
Date of Web Publication10-Mar-2016

Correspondence Address:
Anil T Deshmukh
Department of Pathology, Dr P.D.M. Medical College, Amravati - 444 603, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1067.178476

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  Abstract 

Introduction Pancytopenia is an important clinicohaematological entity encountered in our day-to-day clinical practice. The possible underlying aetiologies range from transient viral marrow suppression to left-threatening malignant neoplasm. The aetiological diagnosis is essential for the clinical management and prognosis of the patient.
Materials and methods In this study, a total of 75 cases of pancytopenia/bicytopenia were studied. Complete evaluation of clinical findings, haematological indices and bone marrow examination was carried out.
Results Megaloblastic anaemia (29.3%) was the most common cause of pancytopenia/bicytopenia, followed by hypoplastic/aplastic anaemia (18.6%) and leukaemia (17.3%). Macrocytic anaemia was the predominant finding observed when studying peripheral smears, and a few cases of normocytic or microcytic anaemia were observed. Hypercellular marrow was seen in 68% of cases, whereas hypocellular marrow was present in 21.3% of cases.
Conclusion Haematological indices and bone aspiration complemented with trephine biopsy is a useful, simple, economical and safe diagnostic tool in the evaluation of pancytopenia/bicytopenia. Egyptian J Haematol 41:-0 ͹ 2016 The Egyptian Society of Haematology.

Keywords: bicytopenia, bone marrow, haematological indices, pancytopenia


How to cite this article:
Dagdia KS, Deshmukh AT, Soni RR, Jane DS. Haematological indices and bone marrow morphology in pancytopenia/bicytopenia. Egypt J Haematol 2016;41:23-6

How to cite this URL:
Dagdia KS, Deshmukh AT, Soni RR, Jane DS. Haematological indices and bone marrow morphology in pancytopenia/bicytopenia. Egypt J Haematol [serial online] 2016 [cited 2019 Dec 14];41:23-6. Available from: http://www.ehj.eg.net/text.asp?2016/41/1/23/178476


  Introduction Top


Sir William Harvey described blood as 'the fountain of life and the primary seat of the soul. The marrow of our bones is the seedbed of our blood' [1] .

Peripheral cytopenia is defined as reduction in either of the cellular elements of blood - that is, red cells, white cells or platelets. Bicytopenia is reduction in any of the two cell lines and pancytopenia is reduction in all three [2] .

Pancytopenia is an important clinicohaematological entity encountered in our day-to-day clinical practice. There are varying trends in its clinical pattern, treatment modalities and outcome [3] .

The aetiology of bicytopenia and pancytopenia varies widely, ranging from transient marrow viral suppression to marrow infiltration by life-threatening malignancy. These may also be caused iatrogenically, secondary to certain drugs, chemotherapy or radiotherapy for malignancies [4] .

The possible underlying aetiologies include viral infections, megaloblastic anaemia, nutritional anaemia, hypersplenism, myelofibrosis, leukaemia, myelodysplastic syndrome (MDS), metastasis to bone marrow, parvovirus B19 infection, multiple myeloma, hairy cell leukaemia, and others. Moreover, there are few clear recommendations as regards the optimal investigative approach to pancytopenia [5] .

Thus, the objective of this study was to find the underlying aetiopathology of pancytopenia/bicytopenia.


  Materials and methods Top


This study was carried out at our Hospital from June 2011 to October 2013.

The study included patients of all ages, both sexes, attending the hospital with any of the following complaints such as weakness, giddiness, fever, breathlessness, bleeding tendency and/or body pains. These patients were first subjected to complete clinical examination and further complete haematological workup was carried out. Patients showing all three or any two of the following parameters on complete blood examination were included in the study.

  1. Haemoglobin less than 10 g/dl.
  2. Total leucocyte count less than 4000/mm 3 .
  3. Platelet count less than 1.5 lakh/mm 3 .


Patients fulfilling the above-stated criteria of pancytopenia/bicytopenia were subjected to bone marrow aspiration and trephine biopsy with imprint cytology after due informed consent.

In most of the patients, bone marrow aspiration and trephine biopsy were performed as a complementary procedure and at the same time from the same side or both sides posterior to the superior iliac spine. In some patients only bone marrow aspiration was performed, as neither patient's nor physician's consent was available. There were no exclusion criteria in the study. The detailed clinical history, examination findings and investigations were noted in the patients' medical records.


  Results Top


We studied 75 patients of pancytopenia/bicytopenia during the period from June 2011 to October 2013 in our department. Full clinical and laboratory data were recorded and analysed in detail.

Among the 75 patients studied, 35 patients were male and 40 patients were female, with a male-to-female ratio of 0.87 : 1.

On the basis of the age, patients were divided into four groups: (i) 1-20 years (17 cases); (ii) 21-40 years (21 cases); (iii) 41-60 years (19 cases) and (iv) 61-80 years (18 cases), with the maximum number of patients being between 21 and 40 years of age (28%). The difference between age groups was not significant (P = 0.47).

The peripheral smear examination revealed the following: 33 cases of macrocytic anaemia, 29 cases of normocytic anaemia, eight cases of microcytic anaemia and only five cases of dimorphic anaemia.

Causes of pancytopenia/bicytopenia are presented in [Table 1]. Megaloblastic anaemia was observed as the most common cause of pancytopenia/bicytopenia among patients in all age groups except in those between 61 and 80 years, in whom aplastic anaemia, acute myeloid leukaemia and MDS were the most common causes, with an incidence of 22.22% each. Aplastic anaemia was reported as the second common cause in patients between 1 and 20 years of age and in those between 41 and 60 years of age, whereas nutritional anaemia was the second common cause in those between 21 and 40 years of age. There was a significant difference observed in various diagnosis related to age group (P = 0.02), signifying the important causes of pancytopenia/bicytopenia based on age group affected ([Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]).
Figure 1 A trephine biopsy section showing hypocellular bone marrow in aplastic anaemia (×40).



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Figure 2 A trephine biopsy section showing hypercellular bone marrow with erythroid hyperplasia in megaloblastic anaemia (×100).



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Figure 3 Acute lymphoid leukaemia-bone marrow aspirate smear with increased cellularity in the form of lymphoblasts with reduction in other normal elements (×400).



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Figure 4 Acute myeloid leukaemia-blast cells with  Auer rods More Details in acute myeloid leukaemia (×1000).



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Figure 5 Acute myeloid leukaemia M6-bone marrow aspirate smear showing increased erythroblasts (>50%) (×400).



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Figure 6 Myelodysplastic syndrome-bone marrow aspirate smear with increased blasts (<19%) in myelodysplastic syndrome-refractory anaemia with excess blasts (RAEB) 2 (×400).



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Table 1 Causes of pancytopenia/bicytopenia


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There was no procedure-related complication in any of the patients.


  Discussion Top


Pancytopenia is a serious haematological problem, which makes the patient prone to anaemic manifestations, infections and bleeding tendency. Underlying it are many diseases, which are diagnosed by means of bone marrow aspiration and trephine biopsy.

In this study carried out from June 2011 to October 2013, we studied 75 cases of pancytopenia/bicytopenia. Information on age, sex, presenting complaints, clinical features and various causes of pancytopenia were collected and compared with that presented in other studies related to pancytopenia/bicytopenia ([Table 2]).
Table 2 Comparison of causes of pancytopenia/bicytopenia in various studies


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In the present study, pancytopenia/bicytopenia was observed slightly more common in the female population (53.33%) compared with the male population (46.67%), with a male-to-female ratio of 0.87 : 1.0, which was statistically not significant.

In the present study, the age of the youngest patient was 5 years, which is similar to that reported in the study by Tilak and Jain [6] . The oldest patient was 80 years of age, which is similar to that reported in the studies by Devi et al. [10] , Gayathri and Kadam [11] and Thakkar et al. [13] .

Maximum number of patients were seen in the age group of 21-40 years, which is similar to that reported in the studies by Khodke et al. [7] , Khunger et al. [9] and Devi and colleagues.

The presenting complaints in this study showed a pattern comparable to most of the other studies, with generalized weakness (84%) being the most common complaint, followed by fever (57.33%), breathlessness (12%) and bleeding manifestations (12%).

Comparison of clinical features in various studies revealed that pallor (100%) was the most common clinical feature in this study, which is comparable to that reported in all above-mentioned studies except the studies by Chhabra et al. [12] and Metikurke et al. [14] . Other presenting features in this study included splenomegaly (20%), hepatomegaly (13%) and lymphadenopathy (10%), which are comparable to that reported in the studies by Thakkar and colleagues and Metikurke and colleagues.

In the present study, megaloblastic anaemia (29.3%) was the most common cause of pancytopenia, followed by aplastic anaemia (18.6%), leukaemia (17.3%) and nutritional anaemia (12%). Other uncommon causes were MDS (8%) and hypersplenism (8%). Rare causes include multiple myeloma, parvovirus B19 infection, hairy cell leukaemia, and metastasis to bone marrow, with an incidence of 1.3% each.


  Conclusion Top


Haematological indices and bone marrow morphology (bone aspiration complemented with trephine biopsy) is a useful, simple, economical and safe diagnostic tool in the evaluation of pancytopenia/bicytopenia and help in arriving at diagnosis in most of the cases. However, in haematological malignancies and MDS it has to be supplemented with immunohistochemical and cytogenetic studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Smock KJ, Perkins SL. Examination of blood and bone marrow. In: Lee GR, Lukons FJ, Paraskevar F, Greer JP, Rodgers GM, eds. Wintrobe′s clinical haematology. 10th ed. Baltimore, MD: Lippincott Williams and Wilkins; 1999:23-32.  Back to cited text no. 1
    
2.
Bates I. Bone marrow biopsy. In: Lewis SM, Bain BJ, Bates I, eds. Dacie and Lewis practical haematology. 10th ed. Philadelphia, PA: Churchill Livingstone; 2006:115-130.  Back to cited text no. 2
    
3.
Tariq M, Khan N, Basri R, Amin S. Aetiology of pancytopenia. Professional Med J 2010; 17 :252-256.  Back to cited text no. 3
    
4.
Naseem S, Varma N, Das R, Ahluwalia J, Sachdeva MU, Marwaha RK. Pediatric patients with bicytopenia/pancytopenia: review of etiologies and clinico-hematological profile at a tertiary center. Indian J Pathol Microbiol 2011; 54 :75-80.  Back to cited text no. 4
    
5.
Ishtiaq O, Baqai HZ, Anwer F, Hussain N. Patterns of pancytopenia patients in a general medical ward and a proposed diagnostic approach. J Ayub Med Coll Abbottabad 2004; 16 :8-13.  Back to cited text no. 5
    
6.
Tilak V, Jain R. Pancytopenia - A clinic hematologic analysis of 77 cases. Indian J Pathol Microbiol 1999; 42 :399-404  Back to cited text no. 6
    
7.
Jha A, Sayami G, Adhikari RC, Panta AD, Jha R. Bone marrow examination in cases of pancytopenia. J Nepal Med Assoc 2008; 47 :12-17.  Back to cited text no. 7
    
8.
Kumar R, Kalra SP, Kumar H, Anand AC, Madan M. Pancytopenia - A six year study. JAPI 2001; 49:1079-81.  Back to cited text no. 8
    
9.
Khunger JM, Arulsevi S, Sharma U, Ranga S, Talib VH. Pancytopenia - A clinic haematological study of 200 cases. Indian J Pathol Microbiol 2002; 45 :375-379.  Back to cited text no. 9
    
10.
Devi PM, Laishram RS, Sharma PS, Singh AM, Singh MK, Singh YM. Clinica-hematological profile of pancytopenia in Manipur, India. Kuwait Med J 2008; 40 :221-224.  Back to cited text no. 10
    
11.
Gayathri BN, Kadam SR. Pancytopenia: a clinic haematological study. J Lab Physicians 2011; 3 :15-20.  Back to cited text no. 11
    
12.
Chhabra A, Chandar V, Patel A, Chandra H. Clinico-aetiological profile of pancytopenia in paediatric practice. JIACM 2012; 13 :282-285.  Back to cited text no. 12
    
13.
Thakkar BB, Bhavsar UN, Trivedi NJ, Agnihotri AS. A study of pancytopenia in adult patients more than 12 years of age in north west region of saurashtra. Natl J Med Res 2013; 3 :48-52.  Back to cited text no. 13
    
14.
Metikurke SH, Rashmi K, Bhavika R. Correlation of bone marrow aspirate, biopsies and touch imprint findings in pancytopenia. J Hematol 2013; 2 :8-13.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

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