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An 84-year-old white female was diagnosed with myelodysplastic syndrome/chronic myelomonocytic leukemia-1 while evaluating thrombocytopenia, macrocytic anemia and persistent monocytosis with absolute monocyte count of 1,500/µL. Her hemoglobin was 11.6 gm/dL, white blood count 5,100/µL, mean corpuscular volume 100.6fL and platelet 73,000/µL. Bone marrow biopsy revealed dysmaturation of myeloid and monocytic series on morphology and on flow cytometry without excess blasts. Other evaluations including vitamin B12 and folic acid were normal. She was lost for follow-up and she did not receive any specific therapy. Two years later, she presented with increasing generalized bone pains of about 2 wks duration. Peripheral smear revealed leucoerythroblastosis with white blood count of 19,600/uL, absolute monocyte count 2400/µL. Her hemoglobin was 8.6gm/dL and platelet count 39,000/µL. Bone scan revealed increased uptake in multiple areas suggestive of leukemic involvement. Peripheral blood flow cytometry revealed left shift of myeloid line with less than 1%; blasts. Bone marrow biopsy revealed extensive granular background consistent with hypercellular necrotic marrow. Cytogenetic analysis revealed normal female karyotype in six metaphases available for analysis. Flow cytometry could not be performed due to non-viable cells. Other evaluations including, anti-phospholipid antibodies, TB test (QFT), blood cultures were all negative. Patient preferred supportive care only. Figure shows bone marrow with almost complete loss of nuclei reflective of extensive necrosis of bone marrow components between intact bone trabeculæ.
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