Bilinmeyen Ateş Etiyolojisinde Girişimsel Hematolojik Tetkiklerin Yeri

Yıl 2018, Cilt: 18 Sayı: 1, 76 - 83, 28.03.2018

Mehmet Gündüz , Samet Yaman Şule Mine Bakanay Öztürk Ayşe Kalem Kaya Aydan Kılıçarslan Aysun Şentürk Yıkılmaz İmran Hasanoğlu Sema Akıncı Rahmet Güner İmdat Dilek

https://doi.org/10.17098/amj.370672

Öz

Amaç:
Nedeni bilinmeyen
ateş (NBA) etiyolojisi çoğu zaman klinisyenleri
uğraştıran, tanı için invaziv işlemler gerektiren klinik bir tablodur. Kemik
iliği kültürü ve biyopsisi ile lenf nodu biyopsisi bu amaçla tercih edilen
invaziv girişimlerdir. Çalışmamızda NBA etiyolojisi araştırdığımız
hastalarımıza ait bu incelemelerin tanıdaki rolü ve sonuçları tartışılmıştır.

Materyal ve Metot: Ankara
Atatürk Eğitim ve Araştırma Hastanesi Enfeksiyon Hastalıkları Kliniği’nde NBA etiyolojisine
yönelik kemik iliği (Kİ) kültürü ve biyopsisi amacı ile Hematoloji ile konsülte
edilen ve lenf nodu biyopsisi değerlendirilen hastalar incelenerek, tanıda bu
invaziv girişimlerin rolü değerlendirilmiştir.

Bulgular: Kemik iliği kültürü-biyopsisi yapılan 18 erkek, 14 kadın,
toplam 32 hastadan alınan kemik iliği kültürlerinin altısında üreme saptandı.
İki hastada eş zamanlı olarak hem kan, hem de kemik iliği kültüründe üreme
vardı. İki hastanın sadece kemik iliği kültüründe Brucella spp. üredi.Kemik iliği biyopsilerinden 24’ü (%75,00)  normoselüler, 6’sı (%19,00) hiperselüler,
biri (%3,00) lenfoma tutulumu gösteren kemik iliği ve bir diğeri ise poliklonal
plazma hücre artışı gösteren hiposelüler kemik iliği şeklinde raporlandı. Fizik
muayenede lenfadenopatisi saptanan dokuz hastaya lenf nodu biyopsisi  yapıldı. Lenf nodu biyopsileri ile bir
hastada Leishmania spp., bir hastada
EBV  ve iki hastada diffüz büyük B
hücreli non-Hodgkin lenfoma (NHL) saptandı.

Sonuç: NBA etiyolojisinde kemik iliği biyopsisi ve kültürü ve lenf nodu biyopsisi
invaziv tanısal girişimler olup, kemik iliği tutulumu ile seyreden brusella
gibi zoonotik enfeksiyonlar başta olmak üzere lösemi, lenfoma, tüberküloz gibi
durumları ortaya koymada altın standart testtir. NBA etyolojisi araştırılırken
girişimsel hematolojik işlemlerin değeri göz ardı edilmemelidir. Birinci
basamak hekimleri, bu işlemlerin gerekliliği ve zamanlaması konusunda bilgi
sahibi olmalıdır.

Anahtar Kelimeler

Nedeni bilinmeyen ateş etiyoloji, kemik iliği kültürü ve biyopsisi, lenf nodu biyopsisi

The Place of Interventional Hematologic Investigations in Unknown Fever Etiology

Öz

Objectives: Fever of unknown origin (FUO) is a usually challenging clinical condition for physicians. The diagnostic work-up requires invasive procedures including culture of bone marrow aspirates and bone marrow/lymph node biopsies. In this study, we have investigated the results of diagnostic procedures employed for the work-up of FUO.

Materials and Methods: Patients who were requested hematological consultation for bone marrow aspiration for culture during the work-up for FUO in the Infectious Diseases Department of Ankara Atatürk Training and Research Hospital were included in the study. Patients with detected lymphadenopathies during physical examination had also underwent pathological investigation of bone marrow and lymph node biopsies.

Results: Bone marrow cultures revealed positive results in 6 out of 32 patients(18 male and 14 female). Two patients had simultaneous positivity of both blood and bone marrow cultures. Brucella spp. was detected in bone marrow cultures of two other patients. Among the bone marrow biopsies 24(75.00%) were normocellular, 6(19.00%) were hypercellular, 1(3.00%)revealed lymphoma involvement and 1(3.00%) revealed polyclonal expansion of plasma cells. Nine patients with with lymphadenopathies in physical examination were performed lymph node biopsies. Lymph node biopsies demonstrated Leishmania spp. in 1 patient, EBV in 1 patientand diffuse large B-celllymphoma in 2 patients.

Conclusion: Bone marrow biopsy and culture and lymph node biopsy are invasive diagnostic tests for the work-up of FUO. Bone marrow culture is the golden standard for the diagnosis of zoonotic infections including brucellosis and granulomatous infections including tuberculosis, as well as infiltration with leukemia and lymphoma. The value of interventional hematological procedures should not be underestimated during the work-up of FUO. The primary care physicians must be aware of this necessity and of the timing for these procedures.

Anahtar Kelimeler

: Fever of unknown origin etiology, bone marrow culture and biopsy, lymph node biopsy

Kaynakça

• 1. Petersdorf RG, Beeson PB. Fever of unexplained origin: report on 100 cases. Medicine (Baltimore) 1961;40:1-30.
• 2. Kucukardali Y, Oncul O, Cavuslu S, et al. Fever of Unknown Origin Study Group The spectrum of diseases causing fever of unknown origin in Turkey: a multicenter study. Int J Infect Dis 2008;12:71-9.
• 3. Colpan A, Onguru P, Erbay A, et al. Fever of unknown origin: analysis of 71 consecutive cases. Am J Med Sci 2007;334:92-6.
• 4. Bleeker-Rovers CP, Vos FJ, de Kleijn EM, et al. A prospective multicenter study on fever of unknown origin: the yield of a structured diagnostic protocol. Medicine (Baltimore) 2007;86:26-38.
• 5. Kazanjian PH: Fever of unknown origin: Review of 86 patients treated in community hospitals. Clin Infect Dis, 1992;15:968–73.
• 6. Abdulsalam AM, Al-Jahdali HH, Memish ZA, Ahmad AH: Fever of unknown origin. Experience of a large tertiary care hospital in Saudi Arabia. Saudi Med J, 2005;26:352–54. 7. Chin C, Chen YS, Lee SS et al: Fever of unknown origin in Taiwan. Infection, 2006;34(2):75–80.
• 8. Feigin RD. Feigin & Cherry’s Textbook of Pediatric Infectious Diseases. 6th ed. Philadelphia, PA: Saunders/Elsevier; 2009.
• 9. Tolan RW Jr. Fever of unknown origin: a diagnostic approach to this vexing problem. Clin Pediatr (Phila) 2010;49:207-213.
• 10. Bodem CR, Hamory BH, Taylor HM, Kleopfer L. Granulomatous bone marrow disease. Medicine 1983;62 372–83.
• 11. Volk EE, Miller ML, Kirkley BA, Washington JA. The diagnostic usefulness of bone marrow cultures in patients with fever of unknown origin. Am J Clin Pathol 1998;110:150–3. 12. Riley UB, Crawford S, Barrett SP, Abdalla SH. Detection of mycobacteria in bone marrow biopsy specimens taken to investigate pyrexia of unknown origin. J Clin Pathol 1995;48:706–9.
• 13. Basu D, Saravana R, Purushotham B, Ghotekar LH. Granulomas in bone marrow – a study of fourteen cases. Indian J Pathol Microbiol 2005;48:13–6.
• 14. Vilalta-Castel E, Valdes-Sanchez MD, Guerra-Vales JM et al. Significance of granulomas in bone marrow: a study of 40 cases. Eur J Haematol 1988;41:12–6.
• 15. Diebold J, Molina T, Camilleri-Broet S, le Tourneau A, Audouin J. Bone marrow manifestations of infections and systemic diseases observed in bone marrow trephine biopsy. Histopathology 2000;37:199–211.
• 16. Cunha BA. Fever of unknown origin: focused diagnostic approach based on clinical clues from the history, physical examination, and laboratory tests. Infect Dis Clin North Am 2007;21:1137–8.
• 17. Hot A, Jaisson I, Girard C, et al. Yield of bone marrow examination in diagnosing the source of fever of unknown origin. Arch Intern Med 2009;169:2018–23.
• 18. Mourad O, Palda V, Detsky AS. A comprehensive evidence-based approach to fever of unknown origin. Arch Intern Med 2003;163:545–51.
• 19. Singh G. The study of prolonged fevers. JAPI 2000;48:454-5.
• 20. Kleijn EMHAD, Lier HJJV, Group TNFS. Fever of unknown origin (FUO). Diagnostic procedures in a prospective multicenter study of 167 patients. Medicine (Baltimore) 1997;76:401-14.
• 21. Ahmed S, Siddiqui A, Mehrotra B. Diagnostic yield of bone marrow examination in fever of unknown origin. The American Journal of Medicine 2003;115:591.
• 22. Sharma BK, Kumar S, Verma SC. Prolonged undiagnosed fever in northern India. Trop-Georg-Med 1992;44:32. 23. Bain BJ. Bone marrow trephine biopsy. J Clin Pathol. 2001;54:737- 42.
• 24. Kaya A., Ergul N., Yıldız S. The management and the diagnosis of fever of unknown origin, Expert Review of Anti-infective Therapy. 2013;11:8, 805-15.
• 25. Dorfman RF, Remington JS. Value of lymph-node biopsy in the diagnosis of acute acquired toxoplasmosis. N Engl J Med 1973;289:878–81.
• 26. Sinclair S, Beckman E, Ellman L. Biopsy of enlarged, superficial lymph nodes. JAMA 1974;228:602–3. 27. Tsang WY, Chan JK, Ng CS. Kikuchi’s lymphadenitis. A morphologic analysis of 75 cases with special reference to unusual features. Am J Surg Pathol. 1994;18(3):219-31.