Conflict of interest: Nothing to report.
Images in Hematology
Pseudo-Gaucher cells in disseminated mycobacterial infection
Version of Record online: 3 FEB 2012
Copyright © 2012 Wiley Periodicals, Inc.
American Journal of Hematology
Volume 88, Issue 2, page 155, February 2013
How to Cite
Busarla, S. V. P., Sadruddin, F. A. and Sohani, A. R. (2013), Pseudo-Gaucher cells in disseminated mycobacterial infection. Am. J. Hematol., 88: 155. doi: 10.1002/ajh.22269
- Issue online: 24 JAN 2013
- Version of Record online: 3 FEB 2012
- Accepted manuscript online: 3 DEC 2011 05:01AM EST
- Manuscript Accepted: 28 NOV 2011
- Manuscript Received: 16 NOV 2011
The patient was a 27-year-old HIV-positive Kenyan woman (current CD4+ T-cell count of 80/mm3) admitted to the hospital with fever, hypotension, and acute abdominal pain. She was diagnosed with gastroenteritis and, upon further evaluation, was found to be pancytopenic. Her CBC results were as follows: RBC: 2.6 × 1012/L; hemoglobin: 6.9 g/dL; hematocrit: 20%; mean corpuscular volume: 78 fL; platelets: 35 × 109/L; WBC: 2.6 × 109/mm3 with the following differential: neutrophils: 77%, lymphocytes: 14%, monocytes: 7%, eosinophils: 0%, basophils: 2% 1.
She was diagnosed with HIV infection 1 year prior, at which time her CD4+ T-cell count was 167/mm3 (reference range: 380–1080/mm3). At that time, she was started on antiretroviral therapy with lamivudine, tenofovir and nevirapine, and was also empirically started on anti-mycobacterial therapy with rifampin, isoniazid, ethambutol, and pyrazinamide. The patient self-discontinued the anti-mycobacterial therapy several months before admission.
During the current admission, bone marrow trephine biopsy and aspiration were performed to evaluate her pancytopenia. Leishman stain showed decreased hematopoietic elements and scattered admixed macrophages with abundant striated cytoplasm (Pseudo-Gaucher cells) containing numerous negatively-stained bacilli (A). Bacilli were also present extracellularly (B) and were positive with Ziehl-Neelsen stain (B, inset), confirming the presence of mycobacteria. The bone marrow trephine biopsy demonstrated similar findings with aggregates of foamy macrophages replacing much of the hemopoietic marrow (C). Staining of paraffin sections showed intracellular bacilli positive for both Ziehl-Neelsen (not shown) and Periodic acid-Schiff (PAS) stains (D), consistent with atypical mycobacteria. No material was submitted for culture. The patient was restarted on anti-mycobacterial quadruple therapy, but expired on the 15th hospital day.
Pancytopenia in this case was likely due to disseminated mycobacterial infection leading to extensive marrow replacement by histiocytes filled with acid-fast bacilli. The finding of pseudo-Gaucher histiocytes containing negatively-stained bacilli on air-dried Romanowsky-stained smears should lead to the suspicion of possible mycobacterial infection and further diagnostic work-up with special stains [1, 2]. The large number of intracellular bacilli and their simultaneous positivity with both Ziehl-Neelsen and PAS stains on paraffin sections is characteristic of atypical mycobacteria .