Journal of Pathology of Nepal (2012) Vol.

2, 309 - 312
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Original Article

Interpretation of bone marrow aspiration in

hematological disorder
Pudasaini S1, Prasad KBR1, Rauniyar SK1, Shrestha R1, Gautam K1, Pathak R1,
Koirala S1, Manandhar U1, Shrestha B1
1
Department of Pathology, Nepal Medical College Teaching Hospital, Kathmandu, Nepal

ABSTRACT
Keywords:
Background: Hematological disorders are quite frequent in all age group. Most of this hematological
Anemia;
disorder first present as anemia. Bone Marrow Aspiration plays a major role in the diagnosis of its
Bone marrow aspiration;
underlying cause. The aim of this study was to analyze the causes of hematological disorders, its spectrum
Leukemia;
and to interprete the bone marrow aspiration findings.
Megaloblastic anemia
Materials and Methods: This was a retrospective and prospective study carried out in the department
of Pathology of Nepal Medical College in a period of two years. (July 2010 - June 2012). Bone marrow
examination of 57 cases of suspected hematological disorders was carried out. All details of the patients
were obtained from the record file in the department of pathology.
Results: Out of 57 cases of bone marrow aspiration, erythroid hyperplasia was seen in 12 cases (21%).
Megaloblastic anemia was seen in 7 cases (12.3%) and microcytic anemia was seen in 4 cases (7%).
There were 6 cases (10.5%) of Idiopathic Thrombocypenic Purpura. Acute leukemia was diagnosed in 7
cases (12.3%) and among this acute myeloid leukemia (10.5%) was more common than acute lymphoid
leukemia (1.8%). Myelodysplastic syndrome and multiple myeloma was seen in 3.5 % cases each.
Aplastic anemia and kalaazar was seen in 5.3% and 1.8% cases respectively.
Conclusion: Bone marrow examination is an important step to arrive at the confirmatory diagnosis
of many hematological disorders.

INTRODUCTION

Anemia is common worldwide and particularly so in without bone marrow examination the diagnosis is usually
developing countries.1 Hematological disorder in any not a confirmatory. Bone marrow examination also gives
age group usually presents with anemia. The spectrum explanation for unexplained cytopenias and leukemia.2
of hematological disorders is relatively different in the It gives a more complete picture of the reaction of the
developing world than the developed countries.2 Most of hemopoietic tissue to anemia than can be gained from
the time the diagnosis can be arrived at by detail clinical peripheral blood smear (PBS) alone.1
examination and few simple investigations. However
Bone marrow aspiration (BMA) is the most frequent and
Correspondence: safe invasive procedures done routinely in the hospitals for
Dr. Sujata Pudasaini,MD the diagnosis and management of hematological disorder.1-3
Assistant Professor, Department of Pathology There is very little or no risk of bleeding and can be safely
Nepal Medical College Teaching Hospital, Kathmandu, Nepal done in case of severe thrombocytopenia.2
E-mail: [email protected]
Bone marrow aspiration in hematological disorders 310

This study was carried out with the aim of finding out the
causes of haematological disorders, its spectrum and to
interprete the BMA findings.

MATERIALS AND METHODS

This was a retrospective and prospective study done in the

Department of Pathology of Nepal Medical College for a
period of two years July 2010 to June 2012). A total of 57 cases
were included in this study. BMA reports of the patients
were retrieved from the record file in the department. PBS Figure 1: Bone marrow aspirate smears showing LD
along with necessary hematological and clinical parameters bodies (Giemsa stain, X1000)
were also noted from the record file. Geimsa stained slides
along with Iron stain, Periodic Acid Schiff (PAS) stain and
Myeloperoxidase (MPO) stained slides were examined in
the available cases. Aspirates of inadequate material or dry
tap were excluded from the study. Then data was manually
collected and subsequently analyzed.

RESULTS

A total number of 57 patients were included in this study

aged between 9 months and 75 years. The mean age was
37.9 years. 27 (47.4%) were males and 30 (52.6%) were Figure 2: Myeloblast with auer rods in AML (Wright stain,
females with (M:F=1:1.1). Maximum number of patients X1000)
(42.1%) of hematological disorder who underwent BMA
was in the age group of 31- 45 years. Table 1 shows the age
distribution of the patients.

Blood count and PBS revealed anemia in 86% cases.

Pancytopenia was seen in 50 % cases and bicytopenia was
seen in 36% cases. Thrombocytopenia alone was seen in 14
% cases. Though most of the bone marrow was hypercellular
we did come across normocellular marrows as well (Table
2).

Bone marrow examination findings are given in Table 3. Figure 3: Bone marrow aspirate showing plasma cells
(Wright stain,X1000)
Erythroid hyperplasia was the common finding in our study.
In these cases there were no other significant findings. Out
of 12 cases of erythroid hyperplasia, 2 cases show few The differential diagnosis of megaloblastic anemia was
micronormoblast and 3 cases show mild megaloblastoid commented in each of these cases as clinical correlation with
changes however they were not of the significant number. biochemical and other parameters are required to diagnose.
Hence they were grouped under erythroid hyperplasia. Acute leukemia was seen in 7 cases (12.3%). Out of this,
Megaloblastic anemia (12.3%) was more common than 6 cases (10.5%) were AML and 1 case (1.8%) was ALL.
microcytic anemia (7%). Infective pathology (12.3%) Out of 6 cases of AML, the commonest type was AML M3
includes all the cases with normal to slightly hypercellular (3 cases; fig.2), followed by AML M2 (2 cases) and AML
marrow with increased myeloid erythroid (M:E) ratio and M1 (1 case). There were 2 cases of multiple myeloma
cells of myelopoiesis showing shift to left. Clsuters of LD where 22% and 16% of the nucleated cells were plasma
bodies were seen (fig.1). cells. Though the diagnosis was given as multiple myeloma
(fig.3), biochemical, radiological and clinical correlation
In all cases of hypoplastic anemia the marrow was was recommended in each case.
hypocellular and all 3 lineages of cell were suppressed.
BMA findings were correlated with PBS which also DISCUSSION
showed pancytopenia. However bone marrow biopsy was
not done in these cases. Myelodysplastic syndrome (MDS) The spectrum of hematological disorders is very wide. Bone
was diagnosed in cases with increased erythroid series of marrow examination is safe and a useful test in reaching the
cells with megaloblastic changes and dyserythropoiesis. final diagnosis.2
311 Pudasaini S et al.

In our study the most common age group undergoing BMA Table1: Age distribution of the patients
was 31- 45 years. In a study done by Niazi et al, the majority Age group No. of patients Percentage (%)
of the patients were from the age group 1- 30 years.4 In our < 15 years 4 7%
study the age of the patients ranged from 9 months and 75
15- 30 years 17 29.9%
years with the mean age of 37.9 years. 27 (47.4%) were
31- 45 years 24 42.1%
males and 30 (52.6%) were females with (M: F=1:1.1). Age
and sex distribution was compared with other studies as >45 years 12 21%
shown in Table 4. Total 57 100%

The commonest indication of BMA was pancytopenia Table 2: Cellularity of the bone marrow in the aspirates
(50 %) followed by bicytopenia (36%). Similar to our smears
finding pancytopenia was the commonest indication in Cellularity of the marrow No. of cases Percentage (%)
a study done by Ahmed et al.7 But in contrast to these Hypercellular 35 61.4%
studies, pancytopenia was the third common indication Normocellular 15 26.3%
(11.9%) in a study done by Bashawri et al.8 In our study,
Hypocelullar 7 12.3%
thrombocytopenia alone was seen in 14 % cases.
Total 57 100%

Erythroid hyperplasia was seen in 12 cases (21%). Similar

finding (19.6% cases of erythroid hyperplasia) was seen in Table 3: Bone marrow examination findings
a study done by Jha et al.6 In a study done by Khodke et al BMA diagnosis No. of cases Percentage (%)
14% cases showed erythroid hyperplasia.9 Erythroid hyperplasia 12 21%
Megaloblastic anemia 7 12.3%
Megaloblastic anemia was 2nd common diagnosis in the Acute leukemia 7 12.3%
present study as well as in studies done by Niazi et al and ITP 6 10.5%
Jha et al.4,6 In a study done by Gayathri et al megaloblastic
Microcytic anemia 4 7%
anemia was the commonest cause of pancytopenia and was
Infective pathology 7 12.3%
the commonest finding in BMA.5 Similar to study done by
Jha et al6, we could not identify the exact deficiency leading Hypoplastic anemia 3 5.3%
to megaloblastic anemia as serum folic acid or vitamin MDS 2 3.5%
B12 levels were not assessed. The increase incidence of Multiple myeloma 2 3.5%
megaloblastic anemia reflects the higher prevalence of Leishmaniasis 1 1.8%
nutritional deficiency in our country. Normal marrow 6 10.5%
Total 57 100%
Microcytic anemia seems to be an uncommon finding as
we came across only 7% cases. However in a study done
Table 4: Comparison of age and sex distribution in differ-
by Ahmad et al, 23.8% cases were microcytic anemia and ent studies
diagnosed as iron deficiency anemia.7
Study Age (years) M:F
Egesie et al1 3-80 1.5:1
Acute leukemia was seen in 7 cases (12.3%). Out of this,
6 cases (10.5%) were AML and 1 case (1.8%) was ALL. Gayathri et al6 2-80 1.2:1
Out of 6 cases of AML, the commonest type was AML M3 Kibria et al2 3.5-80 1:0.59
(3 cases), followed by AML M2 (2 cases) and AML M1 (1 Niazi et al5 1-75 1.7:1
case). Other series also showed that acute leukemia is the Jha et al7 1-79 1.5:1
commonest hematological malignancy and AML is more
common than ALL.1,2,5,6
was based on BMA findings and bone marrow biopsy
Other malignancies in this study were multiple myeloma was not available. It is recommended that both aspiration
(3.5%) and MDS (3.5%). Other series showed the incidence and trephine biopsy be done simultaneously in cases of
of multiple myeloma ranging from 0.94% to 4.1%.2,3,5,6 pancytopenia especially if hypoplastic or aplastic anemia
is suspected though aspiration smears are superior for
We encountered 3.5% cases of multiple myeloma compared morphological details. Bone marrow biopsy provides a
to Kibria et al, Laishram et al and Jha et al who reported more reliable index of cellularity and reveals bone marrow
an incidence of 9.04%, 20.5% and 0.94% in their studies infiltration, fibrosis and granulomas.6 Compared to our
respectively.2,3,5 Other series showed incidence of MDS study 19%, 29% and 14% cases of hypoplastic anemia were
ranging from 2% to 7.9%.2,5,6,9 seen in other studies.5,6,9

Hypoplastic anemia was seen in 3 cases (5.3%). Diagnosis ITP was seen in 6 cases (10.5%). Other studies showed
Bone marrow aspiration in hematological disorders 312

2. Kibria SG, Islam MDU, Chowdhury ASMJ et al. Prevalence 0f

6.21%, 14.5%, 6.8% and 5% cases of ITP respectively in
Hematological Disorder: A Bone Marrow Study of 177 Cases In A
their studies.2,7,9 Private Hospital At Faridpur. Faridpur Med. Coll. J. 2010;5:11-3.
3. Laishram S, Shimray R, Sharma AB, Pukhrambam G, Singh AM,
Infective pathology was seen in 7 cases (12.3%) out of Sharma LDC. Neoplastic lesions in the bone marrow: a 10 year study
which Leishmaniasis was seen in one case (1.8%). Similar in a teaching hospital. JIACM 2008;9:175-8.
finding was seen in a study done by Santra et al.11 Other 4. Niazi M, Raziq FI. The incidence of underlying pathology in
studies showed 2.82%,1.2%, 0.67% of leishmaniasis2,4,6 but pancytopenia- an experience of 89 cases. JPMI 2004;18:76-9.
the maximum number of cases (14%) was seen in a study 5. Gayathri BN, Rao KS. Pancytopenia: a clinic hematologicl study. J
done by Khodke et al.9 Lab Physicians 2011;3:15-20.
6. Jha A, Sayami G, Adhikari RC, Panta D, Jha R. Bone marrow
CONCLUSION examination in cases of pancytopenia. J Nepal Med Assoc
2008;47:12-7.
Bone marrow examination is an important step to 7. Ahmad SQ, Khan OU, Zafar N. Utility of Bone Marrow Examination
arrive at the confirmatory diagnosis of wide varieties of in a Secondary Care Hospital JRMC 2011;15:40-1.
hematological disorders. 8. Bashawri LA. Bone marrow examination. Indications and diagnostic
value. Saudi Medical Journal 2002; 23:191-6.
The commonest cause of pancytopenia in our study was 9. Khodke K, Marwah S, Buxi G, Yadav RB, Chaturvedi NK. Bone
megaloblastic anemia. The study provides a valuable insight Marrow Examination in Cases of Pancytopenia. JIACM 2001;2:55-9.
into the causes of anemia or pancytopenia in our country. 10. Gupta N, Kumar R, Khujuria A. Diagnostic assessment of bone
marrow aspiration smears, touch imprints and trephine biopsy in
haematological disorders. JK Science. 2010;12:130-3.
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