Marked Bone Marrow Necrosis Proceeding Acute Monoblasic Leukemia.
Authors: Zadeh M. Hossein , Sadeghipoor A. , Saadat A. , Keyhani M. 
Published: October 2019

Abstract
Bone marrow necrosis (BMN) is a rare antemortem diagnosis with obscure ethiology. This entity is diagnosed mostly at postmortem examination, but it is also seen during the course of different diseases, mostly malignant.It is characterized morphologically by destruction of hemopoeitic tissue, including the stroma, with preservation of the bone.Conditions associated with BMN include infections, acute and chronic leukemia, Hodgkin’s and non-Hodgkin’s lymphoma, primary thrombocythemia, and metastatic carcinoma. It has also been reported in the presence of antiphospholipid antibodies, previous irradiation, antineoplastic chemotherapy, and during treatment with all-transretinoic acid, fludarabine, interferon alpha, and granulocyte-colony-stimulating factor (G-CSF). Other non-neoplastic conditions include disseminated intravascular coagulation (DIC), sickle cell disease, anorexia nervosa and idiopathic conditions.
The prognosis of patients with bone marrow necrosis secondary to neoplastic diasease is extremely poor. Report of complete recovery of four children with ALL who presented with bone marrow necrosis is documented. The relative frequency of BMN varies among different reports, ranging between 0.37%–6.5% of bone marrows. Elevated serum lactate dehydrogenase and alkaline phosphatase levels are known associated laboratory features and were also seen in our patient. We described a 23 years old woman with bone marrow necrosis who developped acute monoblastic leukemia.She was admitted in May, 2004 with generalized bone pain and normocytic anemia. At that time her bone marrow examination showed bone marrow necrosis. She received mostly supportive care during this phase of her presentation because of the possibility of myelodisplastic syndrome. She did not have much pain and discomfort during this phase of her disease. After 8 months she was readmited with severe generalized bone pain and mild pancytopenia. with possible infection or exacerbation of her disease. Bone marrow aspiration and biopsy were repeated. Cytomorphology, enzyme cytochemistry and results of flow cytometric analysis were compatible with Acute Monoblastic Leukemia with mimimal differentiation 80% nonerythroid bone marrow cells are monocyte lineage(AML/M5a), monoblast granules were nonspecific esterase positive, myeloperoxidase negative and more mature monocyte lineage cells had weakly myeloperoxidase positive naphtol b-esterse was positive, naphtol a-estterase was negative and flow cytometic antibody percent on total leukocyte gate were CD45(98%),HLA-DR(89%),CD13(10%),CD33(10%),CD14(0.2%) and CD 34(1 %)CD41, CD61, glycophorin A were negative.,. Her chromosomal study result was:48–50,XX,+6,+8,add(8)(p23),+9,ADD(9)(p24),+14[17]/46,XX[3] and didn’t show a specific abnormality.
Induction chemotherapy was immediately administered. 7 days cytarabine plus 3 days Daunorobicine standard protocol.Copmlete remission was achived on day 28 of induction therapy.
After complete remission on day 28 she did not have bone marrow fibrosis anymore. She received consalidation chemotherapy Our consalidation protocol was:cytarabine 100 mg/bid/sq for 5 day and Mitoxantrone 10 mg/M2 day one altrnative with cytarabine 100 mg/bid/sq *5 day with Danarobicin 45 mg/M2 day 1–2 for six courses.
At present time after complete consalidation course she is in complete remission with no evidence of disease.