Pancytopenia with focal serous atrophy (gelatinous transformation) of the bone marrow

While the myriad of clonal and non-clonal causes of pancytopenia are well outlined [1], we found the following case particularly illustrative to the practicing clinical hematologist, as it highlights the importance of careful morphological evaluation of the marrow for focal abnormalities in an otherwise complex patient. Briefly, a 72-year-old male was admitted to the ICU with hyperglycemia and metabolic derangements and found to have new pancytopenia and severe neutropenia (Hgb 8.9 g/dL, PLT 140 × 10⁹/L, WBC 1.2 × 10⁹/L, ANC 460/μL). He had a history of stage IV mantle cell lymphoma treated with 6 cycles of bendamustine and rituximab, with the last cycle 5 months prior to index hospitalization, and had obtained marked response. CT scans 2 months prior to admission and again with the current hospitalization showed no evidence of worsening lymphoma. It was noted that the patient had obtained count recovery following chemotherapy with normal CBC indices documented just 3 months prior to the current hospitalization. His recent clinical history was one of progressive debility and functional decline, unintentional weight loss (30 lbs over the last 6 months), and he would be accurately described as malnourished and cachectic in appearance. Initial workup for infection, hemolysis, or other causes of cytopenias was unrevealing. A bone marrow biopsy was obtained, and images from the bone marrow core biopsy are shown in Fig. 1. There was no evidence of recurrent lymphoma or other clonal process explaining his new pancytopenia. Rather, patchy areas of hypocellularity and fat cell atrophy were seen in association with a generalized decrease of otherwise normal hematopoiesis and focal deposition of an eosinophilic proteinaceous material.

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