QUIZ ON BONE MARROW-MICROCYTIC + APLASTIC.pptx

Bone marrow pathology

1. Normal Bone Marrow Micro-Environment with bone marrow interpretation in Microcytic Anemia and Aplastic Anemia PRESENTER- DR. CHANDRESH KUMAR MODERATOR- DR. LILESHWARI DEWANGAN

2. STRUCTURE OF BONE MARROW CELLULAR ELEMENTS STROMAL ELEMENTS - Erythroid, myeloid & platelet precursors - Fat cells - Lymphocytes - Fibrocytes - Plasma cells - Reticulin fibrils - Macrophages - Blood vessel network - Mast cells - Basement membrane of capillaries - Dendritic cells, Osteoblasts & - Endothelial cells Osteoclasts

3. INDICATIONS OF BONE MARROW EXAMINATION Anemias- Refractory Anemias- CDA, PRCA, MDS - Unexplained abnormal red cell indices. Macrocytic anemia ( to diagnose megaloblastic anemia) IDA – To assess iron stores Leukemias - To differentiate the types of leukemias Unexplained leucopenia/ Agranulocytosis Staging of NHL/ HD Suspected multiple myeloma Unexplained thrombocytopenia ( ITP) Pancytopenia ( Aplastic Anemia/ Leukemias etc.) Unexplained splenomegaly

4. INDICATIONS OF BONE MARROW EXAMINATION Presence of teardrop red cells on peripheral smear ( possible myelofibrofibrosis ) Presence of hairy cells on peripheral smear (possible Hairy cell leukemia ) Tropical diseases like malaria, kala azar / PUO Infiltrative disorders eg. Gaucher’s disease, Niemann pick’s diseas Secondary malignancies (Carcinoma/ small round cell tumors of childhood) Suspected chromosomal disorders in neonates ( rapid confirmation) Confirmation of normal marrow in potential allogenic donor Work-up of amyloidosis ( to detect clonal plasma cell disorder)

5. Bone marrow aspirate Bone marrow biopsy Smears Histologic sections Squash Touch imprints Particle clot sections IHC Flow cytometry Cytogenetics, FISH Molecular genetics microbiology

6. Bone marrow aspirate Bone marrow biopsy Simple, safe, relatively painless Can be done in OPD Individual cell morphology is preserved Arrangement of cells in marrow spaces & relationship of cells with one another can be studied Fibrotic marrow can be studied

7. ADEQUATE BONE MARROW ASPIRATE & BIOPSY BONE MARROW ASPIRATE- No specific guidelines Presence of marrow particles (during procedure./ naked eye examination) Smear should have many particles with good cell trails BONE MARROW BIOPSY Five or six intertrabecular spaces is desirable A core of 20-30 mm in length

8. BONE MARROW ASPIRATION INTERPRETATION NAKED EYE EXAMINATION - Marrow fragments, spreading, staining Trails are ideal for morphology and differential count Marrow fragments on the tail side are excellent SCANNER AND LOW POWER - Cellularity of the fragments Megakaryocytes- morphology and sequential maturation stages Clusters of abnormal cells- Lymphoma/ metastasis etc Macrophages/ Hemophagocytosis / Granuloma/ Fungus etc Abnormal infiltates

9. BONE MARROW ASPIRATION INTERPRETATION HIGH POWER – Differential count Erythroid, myeloid, lymphoid, plasma cells and others Determine M:E ratio Morphology of cells Iron stain Bone marrow necrosis

10. BONE MARROW ASPIRATION INTERPRETATION ASSESSING CELLULARITY- Cell : Fat ratio (average of many particles) Difficult in aspirate smears 100- age 30-80 % is normal - Cellularity is inversely proportional to age

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12. APPROACH TO BONE MARROW BIOPSY INTERPRETATION Cellularity Topography Morphology Accessory structures Special stains/IHC

13. Initial Assessment Scanner view- adequacy, composition, cellularity, megakaryocytes crushing/ fixing artefacts Low power- diffuse, focal, focal lesions- granulomas, metastasis, lymphomas High power- hemopoietic cells & stromal elements Oil emersion- cytological details, micro-organisms

14. CELLULARITY First decade, marrow cellularity- 80% Gradually decreasing to around 30% by 8th decade Unexplained cytopenia, a fat content >70% reflects hypoplasia Decreased cellularity with stromal fibrosis- hypocellularity AGE SITE CELLULARITY ( HEMOPOIETIC CELLS/ FAT) Neonate All bones, liver, Spleen 100/0 Child Most of bones 70/30 Adult Axial skeleton 50/50 Old age Axial skeleton 30/70

15. TOPOGRAPHY ERYTHROPOISIS- Intertrabecular location Surrounding central macrophages Immature cells- in the center of island Mature cells are in the periphery of the island GRANULOPOIESIS- Paratrabecular in location Immature cells towards the trabecular bone Maturing cells towards the marrow space

16. TOPOGRAPHY cont … MEGAKARYOPOIESIS Uniformly distributed in central part of marrow Parasinusoidal location 30-150 microns- highly pleomorphic Mature megakaryocytes- eosinophilic cytoplasm with variable granularity Nucleus is coarsely cerebriform and multilobated MACROPHAGES - 20-30 micron in dia. - Present in the center of erythroid island and adjacent to endothelial cells Identified as irregularly scattered, relatively large cell with small nucleus and abundant cytoplasm

17. TOPOGRAPHY.. LYMPHOPOIESIS- lymphoblasts- intertrabecular location High N:C ratio, narrow rim of deep blue cytoplasm, hyperchromatic nucleus with one or two nucleoli In adults- lymphocytes are small, randomly interspersed between hemopoietic cells May form small aggregates that increase with age 1-3 aggregates /trephine biopsy- never paratrabecular , mostly mature population with occasional germinal centre (5% cases)

18. TOPOGRAPHY.. PLASMA CELLS: Along the adventitia of small blood vesssels Can also be found singly and in groups all through the intertrabecular locations MARROW STROMA: -Bone marrow stromal cells consist of adipocytes, osteoblasts, osteoclasts, endothelial cells and fibroblast like reticular cells. - Adipocytes are inversely proportional to the hematopoietic cells

19. ERYTHROID CELLS IN BONE MARROW

20. GRANULOCYTE MATURATION IN BONE MARROW

21. MATURATION OF MEGAKARYOCYTIC CELLS IN BM

22. Eosinophils (10–17 μm ) have abundant cytoplasm with numerous coarse, bright red to orange refractile granules of uniform size, segmented nuclei with two or three lobes connected by thin filaments of chromatin, and coarsely clumped nuclear chromatin Basophils (10–15 μm ) have abundant cytoplasm with coarse, dense, purple to dark granules, which vary in size and shape, are unevenly distributed in the cytoplasm, overlie the nucleus, and obscure segmented nuclei with two or three lobes

23. Lymphocytes are small cells (7–15 μ m) with a single, round, ovoid, or slightly indented nucleus, a scant to moderate amount of cytoplasm (N/C ratio 2:1 to 5:1), pale blue color, and sometimes a perinuclear halo, diffusely dense chromatin, and no visible nucleoli. Some larger lymphocytes may have variable numbers of coarse, azurophilic granules in the cytoplasm

24. MONOBLAST (13-15 microns) Large nucleus with fine chromatin .may have indentation. Multiple Nucleoli present. Basophilic cytoplasm PROMONOCYTE (12-14microns) Oval/indented/lobulated nucleus and centrally placed. Open chromatin ,1-2 nucleoli present. Abundant blue cytoplasm

25. Cells of monocytic series demonstrate NSE positivity MONOCYTE (10-12 microns) Nucleus is reniform and lobulated/indented with glassy chromatin. No nucleoli. Pale blue ,ground glass cytoplasm with azurophilic granules , vacuoles may be present. Less than 1% of bm cells

26. .. Macrophage - Large cells (15–80 μ m) with an irregular shape and shaggy margins, abundant blue to pale-pink cytoplasm with large, amorphous debris or phagocytosed materials, often vacuoles, azurophilic granules and pseudopodia, an eccentric nucleus with reticulated chromatin, and one or more small nucleoli

27. Adipocyte at the center, surrounded by hematopoietic cells. Large (25–80 μ m), with abundant pale blue to colorless cytoplasm containing numerous large fat vacuoles and delicate eosinophilic fibrils. They often have an eccentric, small, oval to round nucleus, dense chromatin, and small nucleoli

28. Hematogones are small- to intermediate-sized cells with very scant cytoplasm, a round to slightly irregular nucleus, dense homogenous chromatin, and indistinct nucleoli. *Hematogones are benign lymphocyte precursors encountered in the bone marrow of an infant or a young child, associated with solid tumors, after aggressive chemotherapy or transplantation, or in an immunosuppressed state.

29. MAST CELLS- originate from multipotent myeloid stem cells. -These are oval or elongated cells with a central nucleus and the cytoplasm is packed with granules which stain deep purple with Giemsa stain. -In the marrow biopsy sections mast cells appear as elongated cells and are difficult to make out on H and E staining, however are discerned on Giemsa staining of the section, PAS stain, toluidine blue, mast cell tryptase and CD117 Mast cells are increased in aplastic anemia , some myeloproliferative neoplasms and mast cell disease

30. Osteoblasts : Bone-forming cells, are large cells (20–50 μm ) with an oval, comet, or tadpole shape, abundant deep basophilic cytoplasm with indistinct borders, an eccentrically located or partially extruded, single round to oval nucleus with reticular chromatin, prominent Golgi apparatus, called the hof , or pale, staining cytoplasm away from the nucleus, and one or more nucleoli.

31. Osteoclasts : Cells involved in the bone resorption , are very large cells (> 100 μm ) with oval to irregular shape, abundant cytoplasm, and coarse granules with variable blue, reddish-purple, or pale pink staining; distinct, multiple nuclei, which are relatively uniformly shaped and widely separated with reticular chromatin, and one or more prominent nucleoli.

32. Bony trabeculae are lined by plump Osteoblasts . In cases of osteogenesis and especially in bone marrow aspirates of children, many osteoblasts are seen Osteocytes are small cells present as dot like nuclei in the lacunae of the bony trabeculae Bone marrow core biopsy section from a child shows two large Osteoclasts with multiple separate nuclei and abundant cytoplasm, adjacent to bone trabecula

33. Plasma cells are medium-sized (8–20 μm ), round to oval cells with a moderate amount of deep basophilic cytoplasm, an eccentric, round nucleus, coarse, clumped chromatin, often with a wheel-like pattern, a prominent perinuclear hof , called the Golgi zone, or pale staining in the perinuclear cytoplasm, sometimes with small cytoplasmic vacuoles and no nucleoli

34. BONE MARROW STROMA Made up of stromal cells & stromal matrix Forms microenvironment of marrow Controls proliferation and growth of stem cells & progenitor cells The various cells are specialized fibroblasts (myofibroblast adventitial reticular cells), fat cells, macrophages, lymphocytes, endothelial cells of capillaries and sinusoids and reticulum cells

35. Medullary arteries enter the marrow via the cortical bone. The smaller branches divide into arterioles and then capillaries, which lead to sinusoids. Sinusoids are lined by endothelial cells and have a fenestrated basement membrane . Sinusoids drain into veins, and are usually in a state of collapse. Whenever dilated as in myelofibrosis , sinusoidal outline is well made out Diseases of the blood vessels like arteritis, amyloidosis and arteriosclerosis can be diagnosed in a trephine biopsy. Amyloid deposition in systemic Amyloidosis . Endothelial cells lining sinuses/capillaries

36. REACTIVE CHANGES IN THE BONE MARROW Two types of changes result from development of an inflammatory response or immune disorder: 1) stromal reactions 2) hemopoietic cell line stimulation Acute inflammation BM biopsy shows reactive changes with preponderance of neutrophils and myeloid cells in a case of septicemia

37. reactive changes… Exudative : interstitial edema with arteriocapillary congestion Hyaline material between adipocytes without HSC PAS +, Alcian blue- Haemorrhagic : Hmg in marrow stroma Suppurative : Marrow occurs as basophilic cellular debris with neutrophils with tissue and bone destruction Necrotic: Foci of necrosis seen secondary to arteriolar thrombosis ,seen in pts of septicimeia , BE, infections Seen as blue acellular granular material

38. REACTIVE CHANGES IN CELL LINES

39. GELATINOUS MARROW TRANSFORMATION ( STARVATION MARROW/ SEROUS ATROPHY) Bone marrow biopsy demonstrates loss of marrow elements and prominent extracellular deposition of an amorphous, gelatinous-appearing matrix Bone marrow biopsy showing extracellular matrix seen in states of cachexia, composed of hyaluronic acid, which stains blue on Alcian blue stain as shown here

40. BONE MARROW FIBROSIS

41. MARROW FIBROSIS BY BAUERMEISTER’S GRADING A- Grade 1 : Occasional fine reticulin fibrils. B- Grade 2 : Very fine few reticulin fibrils on silver impregnation stain with no intersections

42. MARROW FIBROSIS BY BAUERMEISTER’S GRADING C. Grade 3: Coarse fibrils amongst reticulin fibril network with extensive intersections Grade 3 Hemopoietic cells demonstrate streaming of cells because of increased reticulin and marrow sinusoids are dilated (black arrow)

43. MARROW FIBROSIS BY BAUERMEISTER’S GRADING Grade 4 reticulin : Extensive fibrosis of marrow is seen as pink staining collagen fibrils with replacement of hematopoietic cells of the marrow The collagen fibrils stain blue with Masson’s trichome stain in a case of idiopathic myelofibrosis

44. European consensus grading of bone marrow fibrosis (MF) (Thiele et al 2005) (WHO, 2008 ) Reticulin grading WHO 2008 (A) Grade MF-0 few linear reticulin fibrils with no intersections (B) Grade MF-1 loose fibril network throughout the marrow

45. European consensus grading of bone marrow fibrosis (MF) (Thiele et al 2005) (WHO, 2008 ) Reticulin grading WHO 2008 (C) Grade MF-2 diffuse and dense reticulin with extensive intersection (D) Grade MF-3 Marrow collagenisation with osteosclerosis

46. IRON STORES IN BONE MARROW Increased stores- golden brown pigment, in the macrophages and lying free in marrow particles. Following Perls stain iron is graded from 0-6, low to normal grade 1-3 and increased iron stores grade 4-6, Normoblasts with iron granules- sideroblasts are examined under oil immersion and classified as -normal sideroblast (with 1-2 pin prick size granules) -abnormal sideroblasts (coarse 1-5 granules) -ring sideroblasts (with > 5 granules in a perinuclear ring) Iron should be assessed only in marrow particles. Multiple fragments are needed since iron distribution is not uniform in all fragments

47. PERLS' IRON STAIN FOR BMA The fixative of choice is formol -methanol (ratio 1 : 9 for 15 minutes), however methanol alone is also adequate. The staining solution comprises of equal quantities of 2% hydrochloric acid and 4% potassium ferrocyanide . A working solution is prepared by mixing 2 ml of each reagent. The solution is poured on the fixed slide for 20 minute arid then washed with distilled water for 5 minutes. Counterstaining is done with 1% neutral red., nuclear fast red or safranin Slides are graded and interpreted

48. (A) Grade1 iron stores in the marrow - only few macrophages show hemosiderin granules (B) Grade2 iron stores - Many macrophages show hemosiderin granules, visible with a few power lens.

49. (C) Grade3 iron in the marrow is characterized by numerous small hemosiderin granules in all particles. (D) Grade4 iron demonstrates large granules in small clumps. Hemosiderin granules are present both intracellularly (in macrophages) and extracellularly. Grade 4 iron stores indicates increased iron stores

50. ( E)Grade5 There is marked Increase in iron stores and dense large clumps of hemosiderin granules are seen (F)Grade6 The marrow shows massive increase in iron stores. Large deposits of iron obscure the marrow cells

51. ASSESSING IRON STORES ON THE BMB

52. Grade1 Hemosiderin is discerned as golden brown pigment, moderately increased iron stores. Grade2 Focal deposits of hemosiderin laden macrophages are seen. There is non-uniform distribution of iron in the bone marrow.

53. ( C)Grade3 iron in the marrow biopsy is seen as granules in every high power field in one/more cells. (D)Grade4 : There are massive abnormal deposits of iron with clumps of heavy granules, Morphology of the marrow cells is obscured by such heavy deposits of hemosiderin.

54. MICROCYTIC HYPOCHROMIC ANEMIA

55. IRON DEFICIENCY ANEMIA Etiology- Genetic forms, Dietary deficiency, malabsorption, increased blood loss increased physiological demands, infections Pathogenesis - impaired Hb synthesis, impaired cellular proliferation, diminished iron containing proteins, reduced red cell survival Clinical features- fatigue, palpitation, headache, dizziness, breathlessness, irritability, changes in cognition, Pica, thin and flattened fingernails, koilonychia, bald tongue, angular stomatitis, Pharyngeal webs & dysphagia (Plummer Vinson syndrome) chronic atrophic gastritis, congestive heart failure, decreased immunity, Reduced T3 production, restless legs syndrome, SOB, perinatal and child mortality, LBW, prematurity etc.

56. IRON DEFICIENCY ANEMIA… PBS - - MCV<80 fl , MCH < 25 pg , RDW (> 15%), RDW of > 17.1 is diagnostic of pure iron deficiency anemia, MCHC < 27 g/dl. Mild to moderate anisopoikilocytosis Microcytic hypochromic RBCs, poikilocytosis+, pencil cells+, ring cells+ Retic 1-2% Platelets- increased BONE MARROW FEATURES-

57. IRON DEFICIENCY ANEMIA BONE MARROW FEATURES- Hypercellular Micronormoblastic reaction Erythroid hyperplasia (less as compared to degree of anemia ) M:E ratio- 2:1 to 1:2 Normoblasts are smaller, late micronormoblast demonstrates persistent basophilia & fraying of cytoplasmic borders Late niormoblast shows pale area in cytoplasm Mild to moderate dyserythropoiesis –nuclear budding, karyorrhexis Myelopoiesis and megakaryopoiesis are normal Prussian blue staining shows absent iron and no sideroblasts

58. THALASSEMIA MAJOR Pathophysiology- accumulation of free a chains , extravascular hemolysis , marrow and bone changes, extramedullary hematopoiesis , HbF synthesis iron overload, increased hepcidin Clinical features- anemia after 3 months of life, failure to thrive, intermittent infections, poor feeding, progressive pallor, hepatosplenomegaly frontal bossing, mongoloid facies, mild hemolytic jaundice, cholelithiasis, hypoxic leg ulcers, hair on end x-ray skull, osteoporosis and osteopenia, delayed growth, myocardial hemosiderosis+, arrythmia, ccf etc

59. THALASSEMIA MAJOR HEMATOLOGICAL FINDINGS- moderate to severe anemia Microcytic hypochromic RBCs, MCV- 50-70 fl , MCHC- 22-32%, MCH 12-20pg Moderate to marked anisopoikilocytosis Many target cells + Central puddle of Hb may be eccentric Basophilic strippling + Nucleated RBCs + (5-40/100wbc) Tear drop cells+, elliptocytes+, fragmented RBCs+, occasional Howel Jolly body+ Retic usually<2%

60. THALASSEMIA MAJOR BONE MARROW- Markedly hypercellular Marked erythroid hyperplasia M:E ration reversed to 1:1 to 1:2 Normoblastic erythropoiesis Some normoblast shows dyserythropoiesis like irregular nuclear and cytoplasmic borders Normoblast demonstrates pink inclusions of free a- chains Basophilic strippling in intermediate and late normoblast Few gaucher like cells may be present Bone marrow iron is markedly increased Myelopoiesis and megakaryopoiesis are normal

61. THALASSEMIA TRAIT & INTERMEDIA PBS - In β thalassemia trait, and in cases of α thalassemia trait microcytosis and sometimes a degree of hypochromia. Basophilic stippling and moderate poikilocytosis + target cells in some cases. Bone marrow cytology- Moderate erythroid hyperplasia. - Erythropoiesis is micronormoblastic Moderate dyserythropoiesis including nuclear lobulation and nuclei of irregular shape Increased siderotic granulation and occasional ring sideroblasts +. Storage iron is commonly increased. Bone marrow histology- Trephine biopsy sections show erythroid hyperplasia and dyserythropoiesis .

62. HbH DISEASE Lack of 3 out of 4 a gene PBS - Marked hypochromia, microcytosis, anisocytosis and poikilocytosis. Polychromasia +, reticulocyte count is elevated. Bone marrow cytology- The bone marrow is hypercellular with marked erythroid hyperplasia, defective haemoglobinization and some dyserythropoietic features Bone marrow histology- hypercellularity due to erythroid hyperplasia.

63. SIDEROBLASTIC ANEMIA Heterogenous group of disorders characterized by amorphous iron deposits in the erythroblast mitochondria giving rise to ring sideroblast Long term- Erythropoietic hemochromatosis Protoporphyrin synthesis is inadequate

64. SIDEROBLASTIC ANEMIA… X- linked sideroblastic anemia- reduced MCV, mild to severe anemia PBS shows microcytic hypochromic RBCs, may be dimorphic Bone marrow examination shows erythroid hyperplasia, normoblast shows inadequate hemoglobinization and cytoplasmic vacuoles Iron stores are increased, ring sideroblast + mainly in late and intermediate normoblast Pearson syndrome- multisystem disorder results from defect in mitochoindrial DNA Infantile sideroblastic anemia with leucopenia and thrombocytopenia Liver and pancreas dysfunction Hepatic and renal failure ultimately Moderately severe anemia , hypercellular/normocellular marrow Vacuolization in myeloid, erythroid precursors Ring sideroblast are mainly early normoblast

65. SIDEROBLASTIC ANEMIA.. DIDMOAD (Wolfram)Syndrome- trilineage dysplasia may be seen ACQUIRED SIDEROBLASTIC ANEMIAS- IDIOPATHIC & CLONAL Idiopathic sideroblastic anemia - due to heteroplasmic point mutations of mitochondrial DNA Ineffective intramedullary erythropoiesis results from accelerated intramedullary apoptosis of erythroid precursors ALA synthase activity is reduced in normoblasts Usually in elderly (mean age 64 yrs )- fatigue and pallor Half of the cases have mild hepatosplenomegaly

66. ACQUIRED SIDEROBLASTIC ANEMIA HEMATOLOGICAL FINDINGS- Moderate anemia, macrocytic to dimorphic in PS Basophilic strippling may be + Red cells from ring sideroblast are microcytic hypochromic Marrow is hypercellular with erythroid hyperplasia Mild megaloblastosis is present Iron stores are increased 25-90% erythroblast shows ring sideroblast Mainly early and intermediate normoblasts are affected

67. ANEMIA OF CHRONIC DISEASE Anemia of inflammation Mild to moderate anemia, variable hypochromia, low s. iron, high iron stores In India it is very common, second to deficiency anemias

68. ACD.. Clinical features- primarly of underlying disease Hb reduced to 5-10 gm% Retic – Normal/reduced RBC- NCNC, later MCHC Unlike IDA microcytosis follows hypochromia Pathogenesis- multifactorial, inflammatory cytokines alters intracellular iron metabolism, upregulation of hepcidin occurs Lactoferrin produced in inflammation by neutrophils binds with Lf receptor on macrophages, competes with transferrin for iron Marrow macrophages liberates IFN, IL1, TNF  inhibit CFU-E Decreased erythropoietin production IL-6 induces hepcidin production by hepatocytes, which blocks release of macrophage iron

69. APLASTIC ANEMIA Characterized by marrow hypoplasia and peripheral cytopenias May be acquired or hereditary Defect or damage to stem cell compartment or marrow microenvironment CD34 cells are substantially reduced Cytotoxic T cell produce y interferon & TNF, which affect mitotic cycle and induce Fas mediated apoptosis

70. AA… Pathophysiology - malfunction of pleuripotent stem cell CFU-GEMM Immune mediated bone marrow suppression theory T- regulatory cells are diminished in AA IFN-y & TNF a produced by T cells affect hemopoietic stem cells Clinical features- anemia, leucopenia, thrombocytopenia Bleeding tendancy - gum bleeding, epistaxis, petechiae, menorrhagia Fever, bronchopneumonia, ear/skin infection, fatigue etc

71. AA Criteria for diagnosis- SEVERE APLASTIC ANEMIA- at least two of following- Granulocyte count <500/ ul , platelet count <20000/ ul , Absolute retic <1%, <40000/ ul In addition, B.M. biopsy < 25% of normal cellularity at that age VERY SEVERE APLASTIC ANEMIA- SAA+ Granulocyte <200/ ul NON SEVERE APLASTIC ANEMIA- Pt. who don’t fulfill SAA criteria, cellularity <30%, depression of 2 or more cell lines and absence of pancytopenia Blood findings- Hb, ANC, platelet count are all decreased Retic <1% PBS- Pancytopenia, NCNC or Macrocytic RBCs, significant neutropenia

72. AA BONE MARROW- diminished hemopoietic precursors, increased fat BMA- dry tap/ diluted marrow BMB is essential for diagnosis May be focal cellular areas having lymphocytes, plasma cells, mast cells Few island of erythroid precursor may show normo /megaloblastic picture Myeloid and megakaryocytic precursors are markedly diminished Few hot pockets of cellularity of erythroid precursors may be prominent Hemosiderin laden macrophages are easy to made out Few hemopoietic foci shows disturbed geography CD34+VE cells are diminished Angiogenesis is diminished

73. Q.1- A TRANSFUSION DEPENDENT ANEMIC CHILD SHOWS STRIKING HYPOCHROMIA, MICROCYTOSIS, ANISOCYTOSIS AND POIKILOCYTOSIS WITH BASOPHILLIC STRIPPLING IN PS. BMA Picture- erythroid hyperplasia and dyserythropoiesis . Several cells contain cytoplasmic inclusions. PROBABLE DIAGNOSIS?

74. Q.2- MODERATELY ANEMIC CHILD SHOWS- PBS - microcytosis and hypochromia BMA - Mild hypercellularity + mild erythroid hyperplasia Many erythroblasts show micronormoblastic maturation and defective haemoglobinization with ragged or vacuolated cytoplasm Iron stain- abnormal sideroblasts + frequent ring sideroblasts Iron stores are increased. BMB- Mild erythroid hyperplasia. Increased storage iron and ring sideroblast

75. Q.3- 66 YEARS OLD PATIENT WITH C/O WEAKNESS AND LETHARGY SHOWS- 1. BMA- severely hypoplastic fragment 2. BMB- showing marked hypocellularity 3. Marked reduction in haemopoietic precursors; many of the remaining cells are plasma cells