Submitter(s): Thierry Jo Molina, Agnes Le Tourneau, Zora Marjanovic, Ors-anton Calendini, Franck Viguie, Christophe Marzac, Jacques Diebold, Josee Audouin.

Clinical history
62 year old female presenting with fatigue. Physical examination detected splenomegaly (6cm below the costs). Absence of previous diseases.
CBC : Hemoglobin : 6.8 g/dl; MCV : 100 fl; WBC : 11x10⁹/l; Neutrophils 70%; Eosinophils : 3%; Lymphocytes 21%; Monocytes 5%; Myeloid precursors 1%; Platelet count 1189 10⁹/l.

Details of gross/microscopic pathology:
Blood : anisocytosis, anisochromia, teardrop poikilocytes; schizocytes : 0.2%; rare erythroblasts. Platelets numerous and heterogeneous in size.
Bone marrow aspirate : Erythroblasts 46.5%; Myeloblasts 2.5%; Promyelocyte 3%; Myelocytes 10%; Metamyelocytes 11.5%; Neutrophils 23%; Eosinophils 1.5%; Lymphocytes 2%; Others non myeloid 2%
The aspirate is hypercellular. It shows important signs of dyserythropoiesis including irregular nuclear contours, maturation asynchronism). Iron stain showed more than 15% ring sideroblasts.Granulopoiesis is active with few signs of dysganulopoiesis (hyposegmentation, degranulation). Megacaryocytes are often of large size.
Bone marrow biopsy submitted fixed in Bouin's liquid and decalcified in RDO (Eurobio, France). Marked increased cellularity [figure1] There is a marked megacaryocytic hyperplasia often clustered (3 to 4) in many areas. [figure2]They showed fairly marked variation in size with dysplastic features. [figure3]Erythropoiesis is hyperplastic with some morphological evidence of dyserythropoiesis.[figure4][figure5]There is also a slight granulocytic hyperplasia with cell maturation.Iron store increase with few stains of erythroblasts.[figure6][figure7]No myelofibrosis on silver stain. [figure8]Marrow Progenitors culture :
CFU-E : No spontaneous erythoblastic differentiation of CFU-E in the absence of EPO; Decrease erythroblastic differentiation in the presence of EPO.
CFU-MK : No spontaneous megakaryocytic differentiation in the absence of growth factor. Decreased megakaryocytic differentiation in the presence of TPO+SCF.

Immunophenotype (flow cytometry/immunohistochemistry):
CD34 on bone marrow biopsy : no increase in blast cell.[figure9]

Cytogenetics:
caryotype : 46, XX, inv (11) (q?12q?14) [19]/46, XX [1].[figure10]

Molecular analysis:
No bcr-abl transcripts by RT-PCR from marrow aspirates. The presence of Jak2 mutation is currently being investigated on this case. There is a presence of jak2 V617F mutation on fresh marrow tissue.

Interesting feature(s) of submitted case:
Rare case of myelodysplastic/myeloproliferative disease unclassifiable : .Refractory anaemia with ring sideroblasts associated with marked thrombocytosis
availability of progenitor cultures in this rare disease
interest of perls stain on bone marrow biopsy with the potential ability to see hemosiderin within erythroblasts after fixation and decalcification.

Proposed diagnosis:
Myelodysplastic/myeloproliferative disease, unclassifiable. Refractory anaemia with ring sideroblasts associated with marked thrombocytosis according to WHO classification.

Panel diagnosis:
agree with proposed diagnosis

Comments:
Additional information from the submitter: There is a presence of JAK2 V617F mutation on fresh marrow tissue.

Comments:
Additional information from the submitter: There is a presence of JAK2 V617F mutation on fresh marrow tissue.

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