Bone marrow emboli following bone marrow procedure

A possible complication

A 65-year-old hypertensive female had pain and swelling in the right axillary region. Clinically, an axillary lymph node was palpable measuring 2 × 2 cm². Biopsy and histopathology revealed a diffuse large B-cell lymphoma, activated B-cell phenotype. Other than mild anemia (Hb 84 g/L), her blood cell counts were unremarkable. A bone marrow examination was performed as a part of lymphoma staging, which did not show infiltration; however, bone marrow elements were seen inside a vessel indicating marrow bone marrow fat embolism (BMFE) [Figure 1a-c].

Figure 1: (a and b) Bone marrow biopsy showing a vessel containing bone marrow elements including megakaryocytes (hematoxylin and eosin stain, 10× (a), 40× (b)). (c) Another vessel showing bone marrow fat emboli (hematoxylin and eosin stain, 40×)

BMFE usually occurs in the far-off sites like in pulmonary vessels following fracture of long bones after accidents, postcardiac resuscitation, acute sickle cell crisis, etc., leading to fat embolism syndrome.[¹] Mechanical disruption of bone marrow can cause fat embolism syndrome previously reported following bone marrow harvesting[²] and transplant.[³] A rare patient had BMFE in the lungs on autopsy following a bone marrow procedure.[⁴] In the present report, the index patient did not have any pre-existing medical conditions, trauma/surgical procedure, or any cardiac resuscitation in the past, which may contribute to the pathology. This is, to our knowledge, the first report demonstrating the presence of BMFE within the bone marrow biopsy. Bone marrow aspiration and biopsy can possibly cause BMFE due to mechanical exposure and silent fracture during the procedure. It can be incidental and was probably asymptomatic in the index case due to focal involvement suggesting a minimal degree of bone marrow embolization. The case is reported for its rarity.

Ethics approval

Institutional Ethical Committee clearance was obtained prior to the conduct of the study.

Availability of data and material

The patient data is available on request from the corresponding author.

Consent to participate

Written informed consent was obtained.

Consent for publication

Patients signed informed consent regarding publishing their data.

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.

Author contributions

Praveen Sharma drafted the article and Aramabam Gautam and Prashant Kumar designed the study and concept. Ritambhara Nada was involved in the diagnostic workup and revision of the article. Pankaj Malhotra provided the clinical data and was involved in patient care. Jasmina Ahluwalia reported the histology and critically revised the manuscript for intellectual content.

Compliance with ethical standards

The study was carried out according to the principles of Declaration of Helsinki 1964 and its revisions. Informed consent was obtained from the patient for publication of data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.