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Year : 2010  |  Volume : 53  |  Issue : 3  |  Page : 577-578
Reactive histiocytosis: A diagnostic dilemma in multiple myeloma

Department of Haematology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India

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Date of Web Publication22-Oct-2010

How to cite this article:
Singh Sachdeva MU, Das R, Ahluwalia J, Varma N. Reactive histiocytosis: A diagnostic dilemma in multiple myeloma. Indian J Pathol Microbiol 2010;53:577-8

How to cite this URL:
Singh Sachdeva MU, Das R, Ahluwalia J, Varma N. Reactive histiocytosis: A diagnostic dilemma in multiple myeloma. Indian J Pathol Microbiol [serial online] 2010 [cited 2021 Oct 25];53:577-8. Available from: https://www.ijpmonline.org/text.asp?2010/53/3/577/68253


A 50-year-old man presented with history of back pain of one and a half year duration. The general physical examination revealed bony tenderness and mild hepatomegaly. Computerized tomography scan showed collapse of L3 vertebra. Fine-needle aspiration cytology from the lesion at L3 region showed numerous mature as well as immature appearing plasma cells and was diagnosed as a plasmacytoma. Hematologic investigations were carried out to rule out multiple myeloma (MM) or other forms of plasma cell dyscrasia. The complete blood count showed hemoglobin of 64 g/L, leukocyte count of 4.4 Χ 10 9 /L, and platelet count of 72 Χ 10 9 /L. The peripheral blood film showed occasional plasma cells, few myelocytes and metamyelocytes, and 2 nucleated red blood cells per 100 white blood cells. Rouleux formation was not seen. The bone marrow aspirate from posterior-superior iliac spine was diluted and showed occasional marrow particles. The most striking feature was the predominance of large histiocytes with abundant granular cytoplasm without any inclusions [Figure 1]a. There were a few scattered plasma cells seen in the bone marrow aspirate smear with a reduction in granulocytic, megakaryocytic, and erythroid series of cells. The large histiocytes were positive with cytochemical staining for nonspecific esterases. The bone marrow trephine biopsy touch smears were more cellular and the differential counts on trephine-touch smears showed 56% plasma cells, eventually resolving the diagnostic dilemma caused by abundant histiocytes seen on the bone marrow aspirate. The trephine biopsy showed hypercellular marrow spaces comprising sheets as well as nodular aggregates of plasma cells admixed with numerous histiocytes. Many of these histiocytes had eosinophilic granular cytoplasm, making it difficult to differentiate them from plasma cells [Figure 1]b. Normal hematopoietic elements were reduced. Immunohistochemical staining for kappa and lambda light chains revealed an overwhelming predominance of kappa light chain-expressing plasma cells [Figure 1]c. Immunostain for lambda chain was negative. Many cells punctuating the sheets of plasma cells remained unstained on kappa as well as lambda immunostaining, and showed bright cytoplasmic positivity for CD68, confirming their histiocytic nature [Figure 1]d.
Figure 1: (a) Bone marrow aspirati on smears showing large granular histi ocytes (Giemsa stain, ×100); (b) bone marrow trephine biopsy showing histi ocytes admixed with sheets of plasma cells (H and E stain, ×100); (c) immunohistochemistry for kappa light chain showing positi vity in the plasma cells (DAB, ×100); (d) immunohistochemistry for CD68 showing positi vity in the histi ocytes (DAB, ×100).

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Reactive histiocytosis might at times produce diagnostic difficulties by obscuring the underlying pathology. In cases of plasma cell dyscrasias, the association of reactive histiocytosis is rare and has been typically described as crystal-storing histiocytosis associated with monoclonal immunoglobulins (MM, monoclonal gammopathy of undetermined significance [MGUS], lymphoplasmacytic lymphoma [LPL], extramedullary plasmacytoma). A review of literature by Lebeau et al reported 34 cases of crystal-storing histiocytosis associated with monoclonal immunoglobulins. [1] It is presumed to be an intralysosomal accumulation of secreted paraproteins or immunoglobulins, which aggregate in crystals. However, our case showed a marked reactive histiocytosis in the bone marrow associated with MM without storing the immunoglobulins. The significance of this unusual finding is speculative. In contrast to immunoglobulin crystal-storing histiocytosis, the literature shows very few reports of non-crystal-storing histiocytosis in MM. [2],[3] Our patient had a poor outcome and expired even before the initiation of therapy. This case is being highlighted due to the peculiar reaction of the histiocytes in MM.

   References Top

1.Lebeau A, Zeindl-Eberhart E, Mόller E, Mόller-Hφcker J, Jungblut P, Emmerich B, et al. Generalized crystal-storing histiocytosis associated with monoclonal gammopathy: molecular analysis of a disorder with rapid clinical course and review of the literature. Blood 2002;100:1817-27.  Back to cited text no. 1      
2.Chantranuwat C. Noncrystallized form of immunoglobulin-storing histiocytosis as a cause of chronic lung infiltration in multiple myeloma. Annals Diag Pathol 2007;11:220-2.  Back to cited text no. 2      
3.Puerto IM, Martinez IB, Ochoa MCO. Bone marrow histiocytosis and multiple myeloma. Haema 2004;7:101-103.  Back to cited text no. 3      

Correspondence Address:
Man Updesh Singh Sachdeva
Department of Haematology, PGIMER, Chandigarh-160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.68253

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