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CASE REPORT
Year : 2020  |  Volume : 16  |  Issue : 1  |  Page : 164-166

Microfilariae in bone marrow aspirate of a case of myelofibrosis: A cause or coincidence?


1 Department of Hematology, SGPGI, Lucknow, Uttar Pradesh, India
2 Department of Pathology, SGPGI, Lucknow, Uttar Pradesh, India

Date of Submission21-Dec-2016
Date of Decision30-Sep-2017
Date of Acceptance09-Apr-2018
Date of Web Publication26-Oct-2018

Correspondence Address:
Khaliqur Rahman
Department of Hematology, SGPGI, Raebareily Road, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_1413_16

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 > Abstract 


Filariasis is among the common parasitic infestations found in India, with Wuchereria bancrofti being the most common causative organism. Presentation ranges from clinically asymptomatic to profound elephantiasis. It is also detected incidentally in diagnostic samples such as body fluids, fine needle aspirates, peripheral blood smears, and other cytological smears. Its detection in bone marrow aspirates with an associated hematolymphoid neoplasm is rare, with only a few case reports. We report one such case of young male who presented with leukocytosis of 253 × 109/L with basophilia and massive splenomegaly. Bone marrow aspirate smears showed the presence of microfilariae along with other features of a myeloproliferative neoplasm (MPN). The present case is probably the first case of finding a microfilaria in a case of MPN.

Keywords: Bone marrow fibrosis, microfilariae, myeloproliferative neoplasm


How to cite this article:
Rahman K, Harankhedkar S, Gupta R, Gupta T, Sharma S, Nityanand S. Microfilariae in bone marrow aspirate of a case of myelofibrosis: A cause or coincidence?. J Can Res Ther 2020;16:164-6

How to cite this URL:
Rahman K, Harankhedkar S, Gupta R, Gupta T, Sharma S, Nityanand S. Microfilariae in bone marrow aspirate of a case of myelofibrosis: A cause or coincidence?. J Can Res Ther [serial online] 2020 [cited 2020 Jun 6];16:164-6. Available from: http://www.cancerjournal.net/text.asp?2020/16/1/164/244202




 > Introduction Top


Filariasis is among the common parasitic infestations found in India. The presence of microfilariae in peripheral blood or a bone marrow aspirate seen in association with a hematological neoplasm is uncommonly described.[1],[2],[3] We present here an unusual case where microfilaria of Wuchereria bancrofti was noted in the bone marrow aspirate of 28 year old patient with myeloproliferative neoplasm.


 > Case Report Top


A 28-year-old male student, resident of Uttar Pradesh, presented with weakness and abdominal fullness for 2–3 months. There was no history of fever, inguinal, or limb swelling. Examination showed massive splenomegaly. Hemoglobin was 108 g/L, total leukocyte count was 253 × 109/L, and platelet count was 480 × 109/L. Peripheral smear examination showed leukocytosis and thrombocytosis along with the presence of myeloid precursors (13%) and basophilia (2%). A provisional diagnosis of MPN was put forth. The patient was put on hydroxyurea with a plan for bone marrow examination and genetic studies. Bone marrow examination procedure could be done after 18 days, by when the total leukocyte count (TLC) had dropped down to 20 × 109/L. The procedure was difficult, and the aspiration smears were hemodiluted with large platelet clumps and giant platelets. Microfilariae of Wuchereria bancrofti were observed in the stained smears [Figure 1]. The wet smears showed the presence of moving microfilariae. Imprint smears were hypercellular, showing increase in megakaryocytic population, at places seen in clusters and displaying mild features of atypia. There was proliferation of myeloid series cells which showed shift to left with 3% blasts and 2% basophils. Bone marrow biopsy showed the presence of Grade 2 fibrosis. Molecular workup with reverse transcriptase polymerase chain reaction for BCR-ABL1 transcript and amplification refractory mutation system for JAK2 V617F mutation analysis was negative [Figure 2]. Conventional karyotype showed a normal male karyotype, 46 XY. The MPL and calreticulin (CALR) mutation studies were also negative. A final diagnosis of primary myelofiborosis (PMF) with microfilariae infestation was considered. The patient was treated with diethylcarbamazine for filarial infestation. He was administered hydroxyurea in graded dose according to the TLC. After 16 months of follow-up, the spleen size has reduced, his counts are normalized, and he is continuing with hydroxyurea 500 mg OD.
Figure 1: Photomicrographs showing hemodiluted bone marrow aspiration smears showing microfilaria against large platelet clumps and giant platelets (a: MGG, ×4). Microfilaria in higher magnification (b: MGG Oil immersion). Imprint smears show megakaryocytic proliferation with clustering and displaying nuclear atypia (c: MGG, ×20). Marrow biopsy showing proliferation of megakaryocytes and marrow fibrosis. Tight clusters of megakaryocytic are seen, some of them show nuclear atypia (d: H and E, ×10). Reticulin stain displaying increased fibrosis, Grade 2–3 reticulin fibrosis (e and inset)

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Figure 2: Postpolymerase chain reaction analysis on 2% agarose gel shows the absence of JAK2 V617F mutation. The patient sample is showing wildtype band only (a); the patient sample is negative for p210 BCR-ABL1 transcript (b); it is also negative for p190 as seen in lane labeled P3 (c)

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 > Discussion Top


Filariasis forms a major healthcare concern in many parts of India and finds a place in the National Vector Borne Disease Control Programme. Its association with various other pathologies has been reported.[4] Finding of microfilariae in bone marrow aspirate in a patient with hematological neoplasm is infrequent association, with few cases reported in literature.[1],[2],[3] To the best of our knowledge, association of microfilariae with MPN or myelofibrosis has not yet been reported. Sehgal et al .[5] reported the presence of giant ribbon-like platelet mimicking a microfilariae in a JAK 2-positive MPN and stressed on the possibility of misdiagnosis in these type of cases. However, the present case not only showed the presence of microfilariae in the aspirate smears but also the “dancing nematodes” could be seen on fresh-made unfixed unstained films from marrow sample [Figure 2].

The diagnosis of this case remains a dilemma. Platelets being an acute-phase reactant can be increased in parasitic infection and hence can give rise to secondary thrombocytosis.[6] This is usually associated with isolated eosinophilia. Marked leukocytosis with the presence of shift cells and basophilia goes against the secondary cause. A very high leukocyte count at initial presentation with basophilia and BCR-ABL1-negative status suggested a prefibrotic stage of PMF as a probable diagnosis. However, the presence of massive splenomegaly and Grade 2–3 fibrosis does not fit with the cellular phase of PMF. Moreover, the cytogenetic as well as the known molecular-targeted investigations could not reveal any evidence of clonality. Secondary myelofibrosis due to infective causes is usually due to tuberculosis, fungal infections, and HIV infections. Parasitic infection like Leishmania donovani can also show the presence of increased marrow fibrosis.[7] However, microfilarial infestation as a cause of massive splenomegaly and secondary myelofibrosis has also never been reported. Proliferation of megakaryocytes which were seen in clusters and displaying features of atypia favoured a diagnosis of PMF in this case. A probable explanation could be a chronic inflammatory status associated with the presence of microfilariae in the marrow, which could have exacerbated a rapid progression of cellular phase of PMF to an overt PMF. We believe this case to be an MPN–PMF and presence of microfilaria as a coincidental finding.

We conclude that association of microfilariae with MPN is being described for the first time in literature and further research needs to be undertaken to elucidate the role of this common parasite in bone marrow pathologies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We would like to thank Mr. Akhilesh Sharma and Mr. Ashish Misra, Technical Staff, Molecular Hematology Lab.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Rahman K, George S, Sardana M, Mehta A. Microfilariae with acute myeloid leukemia: A common parasite with uncommon association. Indian J Hematol Blood Transfus 2013;29:113-5.  Back to cited text no. 1
    
2.
Sharma P, Tyagi S. An unusual cause of eosinophilia in AML-M4 without the Inv(16) abnormality. J Blood Disord Transfus 2010;1:104.  Back to cited text no. 2
    
3.
Jain S, Dass J, Sharma M, Tyagi S. Common parasite with uncommon association. Mediterr J Hematol Infect Dis 2011;3:e2011015.  Back to cited text no. 3
    
4.
Yenkeshwar PN, Kumbhalkar DT, Bobhate SK. Microfilariae in fine needle aspirates: A report of 22 cases. Indian J Pathol Microbiol 2006;49:365-9.  Back to cited text no. 4
[PUBMED]    
5.
Sehgal T, Sharma P, Naseem P, Verma N. Giant ribbon like platelets mimicking microfilariae in a JAK 2 positive myeloproliferative neoplasm. Hematol Oncol Stem Cell Ther 2016;9:80-1.  Back to cited text no. 5
    
6.
Vora AJ, Lilleyman JS. Secondary thrombocytosis. Arch Dis Child 1993;68:88-90.  Back to cited text no. 6
    
7.
Dhingra KK, Gupta P, Saroha V, Setia N, Khurana N, Singh T, et al. 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. 7
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