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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 8  |  Issue : 2  |  Page : 125-129

Diagnostic outcome of bone marrow aspiration in a pediatric center in Kolkata, India


1 Department of Pathology, Dr. B.C.ROY PGIPS, Bankura, India
2 Department of Microbiology, BSMC, Bankura, India
3 Department of Anatomy, IPGME & R, Kolkata, West Bengal, India

Date of Web Publication17-Jan-2016

Correspondence Address:
Arijit Majumdar
Andul, Howrah - 711 302, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5006.174243

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  Abstract 

Objectives: To study the spectrum of hematological disorders in children at a tertiary care centre in Kolkata, India.
Settings: This study was conducted at the department of Paediarics and the department of Pathology of Dr. B. C. Roy PGIPS, Kolkata. The study period was from January 2012 to December, 2014.
Methods: A retrospective analysis of charts of those patients who underwent bone marrow examination (aspiration) was made. Charts were analyzed in detail regarding history, examination and investigations. All findings were entered on a standard proforma.
Results: BMA from 200 patients were analyzed. Nutritional anemia contributed highest number of cases among the nonneoplastic group. Acute lymphoblastic leukemia was the commonest malignant hematological disorder in the present study.
Conclusion: Common haematologic disorders in our setting are nutritional anaemias and leukaemias. There is need to expand the scope of laboratory investigations beyond morphology.

Keywords: Bone marrow aspiration, indications, outcomes


How to cite this article:
Majumdar A, Wasim NA, Jana A, Biswas S, Bhattacharyya S. Diagnostic outcome of bone marrow aspiration in a pediatric center in Kolkata, India. Indian J Health Sci Biomed Res 2015;8:125-9

How to cite this URL:
Majumdar A, Wasim NA, Jana A, Biswas S, Bhattacharyya S. Diagnostic outcome of bone marrow aspiration in a pediatric center in Kolkata, India. Indian J Health Sci Biomed Res [serial online] 2015 [cited 2019 Dec 6];8:125-9. Available from: http://www.ijournalhs.org/text.asp?2015/8/2/125/174243


  Introduction Top


In pediatric age group, all hematological diseases range from very common disorders such as nutritional deficiency anemia up to very serious like leukemia, or rare as syndromic disorders that affect stem cell differentiation of the bone marrow, e.g., Fanconi's anemia, Diamond-Blackfan syndrome, etc.

Bone marrow examination is an important diagnostic tool in hematology. It is a simple and relatively safe procedure carried out routinely in hospitals for the diagnosis and management of hematological and to some extent nonhematological disorders.

Bone marrow examination is quite a valuable test, which has become very important these days for the diagnosis of hematological disorders. [1],[2] Bone marrow aspiration (BMA) provides reliable information regarding bone marrow cellularity, its architecture and the stage of maturation of different blood cells. [3] It helps in the diagnosis and staging of hematological malignancies, especially leukemias. It also provides detailed information regarding the presence hemoparasites within the bone marrow, the presence of infiltrates and storage diseases. [4] Though an invasive, procedure, it can be easily performed even in the presence of severe thrombocytopenia with little or no risk of bleeding. [4]

Various studies have identified different indications for bone marrow examination. A study by Bashawri, identified pancytopenia, leukemia, staging of lymphoma among others as the major indications for BMA. [5] In a similar study in Nigeria, Egesie et al. identified anemia as a major indication for BMA. [6] The objective of this study was to determine the sex and age distribution, the pattern of childhood hematological disorders on bone marrow aspirate examination and to identify the common indications for BMA cytology in the pediatric population.


  Materials and Methods Top


Study site

The study was conducted at Dr. B. C. Roy PGIPS, Kolkata, a specialist referral center for the children.

Study design

The bone marrow records from the Department of Pathology from January 2012 to December 2014 were reviewed in retrospect. Only BMA cytology records were reviewed. BMA that resulted in dry tap, inconclusive results and bone marrow biopsies were excluded from the study.

Data collection and analysis

A detailed history was taken an along-with physical examination to look specifically for the presence of anemia, lymphadenopathy, and hepatosplenomegaly. Complete blood count including hemoglobin, total and differential leukocyte count, total platelet count, and blood indices were performed using automated hematology analyzer (Sysmex K21). Peripheral blood smear examination was done after Leishman and retic stain.

The age, sex, requesting hospital, indications for marrow aspiration study and diagnosis were collated and analyzed using appropriate statistical package.

Ethical consideration

Ethical approval was obtained from the Ethics and Research Committee of hospital before the commencement of the study.


  Results Top


A total of 200 BMA cytology examinations were carried during the study period. Ages of the patients ranged from 2 months to 12 years. The mean ages of the patients were 3 ± 2.5 years. Among these, 120 (60%) were males and 80 (40%) were females. The male to female ratio was 1.5:1 [Table 1].
Table 1: Age and sex distribution of patients

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The two most common indications for BMA cytology examination were pancytopenia (37.1%) and diagnosis and management of leukemia (30.7%), with a higher frequency occurring in male in both conditions. Other indications for BMA cytology occurred in various proportions [Table 2].
Table 2: Indications for BMA among patients

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Seventy-five percentage (150) of the marrow aspirate had pathological features while 5% (10) were normal marrow aspirate and 20% (40) smears showed reactive marrow hyperplasia [Table 3].
Table 3: Proportions of BMA findings in patients

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Nonmalignant hematological disorders were seen in 86 (43%) patients [Table 4] and malignant hematological disorders were seen in 64 (32%) patients [Table 5]. The relationship between indication and outcome of bone marrow aspiration is shown in [Table 6].
Table 4: Spectrum of nonmalignant haemaological disorders

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Table 5: Spectrum of malignant haemaological disorders

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Table 6: Relation between indication and outcome of bone marrow aspiration

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  Discussion Top


Hematological disorders include a wide range of diseases ranging from reactive hyperplasia to hematological malignancies. BMA plays a very important role not only in determining the cause of disease but also help in establishing a definitive diagnosis. It's a relatively safe procedure which can be performed on an outpatient basis. This study was conducted to determine the common indications and diagnostic value of BMA cytology examination in children in a resource-poor center.

In this study, we analyzed the data obtained from these patients to know the relative frequency of different hematological disorders. In this study, nutritional anemia was the most common disorder identified similar to a study by Rahim et al. [4] In other similar studies, its frequency ranges from as low as 24% to as high as 68%. [7],[8] Furthermore, evaluation of nutritional anemia showed that mixed nutritional deficiencies occurred more commonly than isolated or single nutrient deficiency. This finding is similar to that reported by Egesie et al.[9] and thus corroborates the observations from previous studies that anemia resulting from nutritional lack rarely occur as a single nutrient deficiency. [10],[11] In addition, the single nutrient deficiency i.e. megaloblastic and iron deficiency anemia (IDA) occurred in almost equal proportion. This contrasts the findings from other studies in which IDA has been reported to be the most common cause of nutritional anemia globally. [12] Thus, bone marrow examination could be used effectively in most cases to determine the cause of anemia.

Idiopathic thrombocytopenia (ITP) was the third most common hematological disorder found on bone marrow examination in our patients. It is the most common cause of mucocutaneous bleeding in children. Its frequency on bone marrow examination varies between 32% to 48%. [13],[14] Fareed et al. found among nonmalignant disorder ITP as the most common in their patients. [15]

Aplastic anemia was the third most common and most lethal nonmalignant disorder found in our patients (10%). Epidemiologically, aplastic anemia has a pattern of geographic variation opposite to that of leukemias, with higher frequency in the developing world than in the industrialized West. [16]

There were five (2.5%) cases of visceral leishmaniasis. Although their incidence is low, but hemoparasites can be a cause of hematological disorders and they should be specifically looked for while examining the bone marrow aspirate. [17]

There was one case (0.5%) of Gaucher's disease. Bone marrow involvement is common in storage disorders. They can present as hematological abnormalities, and BMA helps in confirming the diagnosis. [18]

In our study, 64 (32%) cases of hematological malignancies were found. Of these cases, 51 (79.69%) were of acute leukemia. This shows that acute leukemia is the most common hematological malignancy in our patients. There were 50 (25%) cases of acute lymphoblastic leukemia (ALL) while 1 (0.5%) were of acute myeloid leukemia. Little is known regarding the epidemiology, etiology and, the incidence of childhood cancer in developing countries. The incidence of ALL is found to be lower as compared to the developed countries, as is the case in India and China. [19]

The most common indications for BMA cytology identified in this study in descending order of frequency are pancytopenia, diagnosis and, management of leukemia and ITP. Similar to our study, Pudasaini et al.[20] and Bashawri [21] both reported pancytopenia, diagnosis and management of leukemia as the two most common indications for this procedure. But contrast studies by Damulak and Damen [22] and Tripathy et al. [23] showed anemia as the most common indication for BMA cytology in their studies, These similarities and differences may be due to the wide spectrum of hematological disorders in most climes.


  Conclusion Top


The indications for BMA examination is this study are similar to those reported in other studies. Although BMA is an uncomfortable procedure for the patient and should be performed only when there is a clear clinical indication, it is a useful technique in the diagnoses and management of a wide range of hematological and some nonhematological diseases especially in a resource-poor center like ours. However, it should be combined with biopsy as a complete study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[23]

 
  References Top

1.
Dacie JV, Lewis SM, editors. Dacie and Lewis Practical Hematology. 8 th ed. Edinburgh: Churchill Livingstone; 1994.  Back to cited text no. 1
    
2.
Sitalakshmi S, Srikrishna A, Devi S, Damodar P, Alexander B. The diagnostic utility of bone marrow trephine biopsies. Indian J Pathol Microbiol 2005;48:173-6.  Back to cited text no. 2
    
3.
Bain BJ. Bone marrow biopsy morbidity: Review of 2003. J Clin Pathol 2005;58:406-8.  Back to cited text no. 3
    
4.
Rahim F, Ahmad I, Islam S, Hussain M, Khattak TA, Bano Q. Spectrum of hematological disorders in children observed in 424 consecutive bone marrow aspirations/biopsies. Pak J Med Sci 2005;21:433-6.  Back to cited text no. 4
    
5.
Bashawri LA. Bone marrow examination. Indications and diagnostic value. Saudi Med J 2002;23:191-6.  Back to cited text no. 5
    
6.
Egesie OJ, Joseph DE, Egesie UG, Ewuga JO. Epidemiology of anaemia necessitating bone marrow aspiration cytology in Jos. Niger Med J 2009;50:61-3.  Back to cited text no. 6
  Medknow Journal  
7.
Mussarat N, Raziq F. The nincidence of underlying pathology in pan cytopenia. An experience of 89 cases. J Postgrad Med Inst 2004;18:76-9.  Back to cited text no. 7
    
8.
Ng SC, Kuperan P, Chan KS, Bosco J, Chan GL. Megaloblastic anaemia - A review from University Hospital, Kuala Lumpur. Ann Acad Med Singapore 1988;17:261-6.  Back to cited text no. 8
    
9.
Egesie OJ, Joseph DE, Egesie UG, Ewuga JO. Epidemiology of anaemia necessitating bone marrow aspiration cytology in Jos. Niger Med J 2009;50:61-3.  Back to cited text no. 9
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10.
Carvalho NF, Kenney RD, Carrington PH, Hall DE. Severe nutritional deficiencies in toddlers resulting from health food milk alternatives. Pediatrics 2001;107:E46.  Back to cited text no. 10
    
11.
Kumar R, Sangwan L, Peter R, Bansal S, Malik T. Prevalence and a etiology of nutritional anaemia in children aged 6 month to 60 month in Fatehabad district of Haryana. J Basic Appl Sci 2014;4:317-21.  Back to cited text no. 11
    
12.
Stoltzfus RJ. Iron deficiency: Global prevalence and consequences. Food Nutr Bull 2003;24 4 Suppl: S99-103.  Back to cited text no. 12
    
13.
Ng SC, Kuperan P, Chan KS, Bosco J, Chan GL. Megaloblastic anemia - A review from university hospital, Kuala Lumpur. Ann Acad Med Singapore 1988;17:261.  Back to cited text no. 13
    
14.
Mohammad AJ. Thrombocytopenia in children. J Postgrad Med Inst 2004;18:353-8.  Back to cited text no. 14
    
15.
Fareed TH, Haddad, Wraikat A, Khasawneh R. Analysis of pediatrics bone marrow aspiration results done in King Hussein medical center (K.H.M.C). Int J Biol Med Res 2012;3:1479-81.  Back to cited text no. 15
    
16.
Issaragrisil S, Leaverton PE, Chansung K, Thamprasit T, Porapakham Y, Young NS. The aplastic anemia study group: The incidence of aplastic anaemia in Thailand. Am J Hematol 1999;61:164-8.  Back to cited text no. 16
    
17.
Dhingra KK, Gupta P, Saroha V, Setia N, Khurana N, Singh T. Morphological findings in bone marrow biopsy and aspirate smears of visceral Kala Azar: A review. Indian J Pathol Microbiol 2010;53:96-100.  Back to cited text no. 17
[PUBMED]  Medknow Journal  
18.
Thomas AS, Mehta A, Hughes DA. Gaucher disease: Haematological presentations and complications. Br J Haematol 2014;165:427-40.  Back to cited text no. 18
    
19.
Rajajee S, Desikulu MV, Pushpa V. Survival of childhood acute lymphoblastic leukemia: Experience in Chennai. J Trop Pediatr 1999;45:367-70.  Back to cited text no. 19
    
20.
Pudasaini S, Prasad KB, Rauniyar SK, Shrestha R, Gautaam K, Pathak R, et al. Interpretation of bone marrow aspiration in haematological disorders. J Pathol Napal 2012;2:3099-312.  Back to cited text no. 20
    
21.
Bashawri LA. Bone marrow examination. Indications and diagnostic value. Saudi Med J 2002;23:191-6.  Back to cited text no. 21
    
22.
Damulak OD, Damen JG. Diagnostic outcome of bone marrow aspiration in a new centre in Nigeria. Glob Adv Res J Med Sci 2012;1:166-71.  Back to cited text no. 22
    
23.
Tripathy S, Dudani S. Comparative evaluation of simultaneous bone marrow aspiration and trephine biopsy. Experience from routine haematology practice. Indian J Clin Pract 2013;24:5.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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