Osama Ishtiaq, Muhammad Zahid, Haider Baqai, Muhammad Umer, Atifa Shoaib, Kaukab Bashir.
Hypocellular Myelodysplastic Syndrome presenting as Megaloblastic Anemia.
J Ayub Med Coll Abottabad Jan ;14(3):29-30.

A 22 years old young male, presented to us in June 2001 with complaints of fever and generalized weakness. He was pale and had very small palpable axillary lymph nodes with no visceromegaly. He was investigated and found to have pancytopenia (Hb= 8.8 gm/dL, TLC=3.5x10e3/L, Platelets= 87,000x10e3/L, MCV= 99 fL, ESR 45 mm, reticulocytes 3.5%). His bone marrow examination was done which revealed moderate megaloblastic anemia with above normal iron stores. He was put on Tab. Folic acid 5 mg bid with Injection Vitamin B12 IM daily, discharged and advised for follow-up in OPD after 2 weeks. He was kept on this treatment for 1 month. On 10th July, his blood picture was repeated, and again found to have pancytopenia (Hb= 6.6 gm, TLC=3.5x10e3/L, Platelets= 37,000x10e3/L, Reticulocytes= 1.4%). He was again admitted. His Bone marrow examination was repeated and found to have moderate megaloblastic anaemia with dyserythropoietic changes. Trephine biopsy was unsuccessful. He was again sent home and recalled after 1 month. He came back after 1 month with new complaints of fever along with productive cough. His Chest X-Ray, repeat Blood CP and sputum R/E was done. Sputum examination was found positive for Acid Fast Bacilli along with atypical cavitatory infiltrates in the lower zone on a radiograph. He refused bone marrow examination but he had pancytopenia. Considering a possibility of Disseminated Tuberculosis, he was put on Anti-TB drugs along with oral steroids. At this stage, his vitamin B12 and folic acid levels were done, and were found to be within normal range. His Ham`s test was also normal and serum Ferritin was increased. CT Scan chest and abdomen were also done which revealed hepatosplenomegaly, and opacities in the right lower lobe of lung posteriorly. To rule out the possibility of lymphoma, lymph node biopsy was done, which was found to have reactive changes only. Due to hepatosplenomegaly, possibility of aplastic anaemia was ruled out, and because of increased iron stores in bone marrow with negative Ham`s test, Paroxysmal nocturnal haemoglobinuria was also not considered. During his stay in the hospital, he was transfused 20 pints of blood and 30 pints of platelets concentrates. In November 2001, he improved clinically, radiographic findings cleared, but he still had pancytopenia. His bone marrow examination was repeated and his trephine biopsy revealed a Moderately Hypocellular Marrow with dysplastic myelopoiesis and prominent eosinophils and lymphocytes with no evidence of fibrosis. Diagnosis of Myelodysplasia with Hypocellular Marrow was made.

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