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Weekly Chest CasesArchive of Old Cases

Case No : 598 Date 2009-04-13

  • Courtesy of Jee Won Park, Ki Nam Kim, Ki-Nam Lee / Dong-A university hospital
  • Age/Sex 32 / F
  • Chief ComplaintGeneral weakness, anemia
  • Figure 1
  • Figure 2

Diagnosis With Brief Discussion

Diagnosis
Extramedullary hematopoiesis
Radiologic Findings
The PA radiograph showed a smoothly outlined mass posterior to the heart on the both side with paravertebral stripes obliteration. It also demonstrated marked hepatic and splenic enlargement (Fig. 1). The chest CT revealed homogeneously enhancing bilateral paraspinal masses from T8 to T10 vertebral level (Fig. 2, 3). There were multiple GB stones with hepatosplenomegaly (Fig. 4, 5). She was a hereditary spherocytosis patient and underwent splenectomy.
Brief Review
Extramedullary hematopoiesis (EMH) is the proliferation of hematopoietic cells outside of the bone marrow in response to production of too few blood cells to satisfy the body’s demand. This insufficient production is caused by either bone marrow replacement disease (myelofibrosis or chronic myelogenous leukemia) or hemolytic anemia (thalassemia, sickle cell anemia, or hereditary spherocytosis). The liver, spleen, kidney, lymph nodes, and posterior mediastinum are the most common sites of EMH.
Intrathoracic EMH may manifest as a paraosseous mass, interstitial pulmonary abnormality, pleural mass, or hemothorax, either alone or in combination. The paraspinal masses and rib expansion are the most common manifestation of intrathoracic EMH. The paraspinal masses have to be differentiated from lymphadenopathy and neurogenic tumors. Cases of EMH involving the pulmonary interstitium mimick an inflammatory or neoplastic diffuse interstitial process and have occasionally resulted in cardiopulmonary insufficiency. EMH usually regresses or disappears after treatment with blood transfusion and hydroxyurea, splenectomy in cases of spherocytosis, or radiation therapy.
In conclusion, the combination of homogeneously enhancing bilateral paraspinal masses with hepatosplenomegaly and gallstones, which occur frequently in hereditary spherocytosis patient makes EMH the most likely diagnosis.
References
1.Yahya M. Berkmen and Benjamin A. Zalta. Case 126: Extramedullary Hematopoiesis Radiology 2007; 245: 905-908
2.Christos S. Georgiades, Edward G. Neyman, Isaac R. Francis, Michael B. Sneider, and Elliot K. Fishman Typical and Atypical Presentations of Extramedullary Hemopoiesis Am. J. Roentgenol. 2002; 179: 1239 - 1243
Keywords
Paravertebral, Multiple organ,

No. of Applicants : 100

▶ Correct Answer : 66/100,  66.0%
  • - Kyungpook National Univ. Hospital , Korea (South) Sang-yub Lee
  • - kyungpook national university hospital , Korea (South) jiwon park
  • - Father Muller Medical College , Mangalore , India nabil mahmood
  • - Assam medical college , India Karunakaran M
  • - WARABI CITY HOSPITAL , Japan YASUO OKUBO
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - Soonchunhyang university Bucheon hospital , Korea (South) Minhee Lee
  • - Seoul Nationial University Bundang Hospital, Korea (South) , Korea (South) Kyoung Jin Oh
  • - Osaka University , Japan Osamu Honda
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - hospital Sao Paulo , Brazil israel missrie
  • - Gimpo Woori Hospital , Korea (South) Son Youl Lee
  • - Apollo Gleneagles hosp , India salim parvez
  • - jaslok hospital & research centre mumbai , India JAINENDRA JAIN
  • - EWHA WOMANS MOKDONG UNIVERSITY HOSPITAL , Korea (South) YOOKYUNG KIM
  • - Barnard Institute of Radiology , India Iyappan Ponnuswamy
  • - Gauhati medical College Hospital , India Hari Krishnan
  • - NTUH , Taiwan Kuei-pin Chung
  • - Chonnam national university hospital , Korea (South) Jae Hoon Lim
  • - Chonnam national university hospital , Korea (South) Jang-hyeon Song
  • - Asian Heart Institute & Apollo clinic , India Jeshil Shah
  • - EKH-Berlin , Germany Michael Weber
  • - Saga University , Japan Ryoko Egashira
  • - Hanmaeum Hospital , Korea (South) Kwon Hyoung Kim
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Yashoda Superspeciality hospital , India Pravin Mahadevappa
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - Louisiana State University - Shreveport , United States Carlos Previgliano
  • - Seoul National University Hospital , Korea (South) Sang Min Lee
  • - The Armed Forces HamPyeong Hospital , Korea (South) Bae Geun Oh
  • - Mackay Memorial Hospital , Taiwan Sheng-Yeh Shen
  • - CHRU Lille , France Benjamin Damarey
  • - Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
  • - Seoul National University Hospital , Korea (South) Kwang Nam Jin
  • - Samsung Medical Center , Korea (South) Hye Sun Hwang
  • - govt royapettah hospital , India gopinathan kathirvelu
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - Consultant Radiologist, London , United Kingdom Shekhar Banavali
  • - Ewha Womans University , Korea (South) Eun Ju Ha
  • - AIIMS , India tariq matin
  • - CH de la Ce Basque , France Paul ARDILOUZE
  • - Soonchunhyang university hospital BUCHEON , Korea (South) Yang ji yeon
  • - Dongguk University International Hospital , Korea (South) Ah-young Kim
  • - , Korea (South) park ji hoon
  • - Al-Afaq MRI centre , Oman Sameer Raniga
  • - SGPGIMS, lucknow, india , India dr soni
  • - Stroger Cook County Hospital , United States Sri Sompalli
  • - The Armed Forces Daegu Hospital, Korea (South) , Korea (South) Hyungwoo Oh
  • - Yonsei University college of medicine Severance Hospital , Korea (South) Hua Sun Kim
  • - Medical IT Consulting , Japan Kazumasa Nishimura
  • - Armed Forces Chun-Cheon Hospital , Korea (South) Chaehun Lim
  • - Vital Imaging Centre, Mumbai,India , India Ganesh Agrawal
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - IRSA , France jean BIGOT
  • - CHU Grenoble , France Fabrice Bing
  • - Soonchunhyang University Cheonan Hospital , Korea (South) Park Sang Hyun
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - McGill University Health Center , Canada Faiza Al Kindi
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - UZ GASTHUISBERG , Belgium Johan COOLEN
  • - Bundang CHA hospital , Korea (South) Jung Jin Young
  • - clinique de SAVOIE , France, Metropolitan gay depassier philippe
  • - All India Institute of medical sciences , India Justin Moses
  • - All India Institute of Medical Sciences , India Ashish Gupta
▶ Correct Answer as Differential Diagnosis : 14/100,  14.0%
  • - Kasturba Medical College Manipal , India Paresh Desai
  • - CHU caen , France nicolas gautier
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - CHRU lille , France manuel toledano
  • - DELHI STATE CANCER INSTITUTE , India VISHAL GARG
  • - Yashoda Super Speciality hospital , India Ramesh Pandey
  • - Trakya Univercity School of Medicine , Turkey Armagan Sarac
  • - MD SKNMC & GH,Pune,Maharashtra, INDIA , India Sushant Bhadane
  • - second hospital xian jiaotong university , China li ming
  • - CHUV , Switzerland Andrea Ojanguren
  • - NASA SCANS , India RAKESH BHATIA
  • - chp st martin , France Mariotte benoit
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - Princess Margaret Hospital , Hong Kong Victor .
▶ Semi-Correct Answer : 5/100,  5.0%
  • - Shiga University of Medical Science , Japan Norihisa Nitta
  • - Shinsegye Rad Clinic, Daegu , Korea (South) Gi Beom Kim
  • - john h stroger hsp , United States dheeraj reddy gopireddy
  • - Univ. of Miami/Jackson Memorial , United States mantosh rattan
  • - Trakya University School of Medicine , Turkey Umut Ugur
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