Necrose de medula óssea: revisão da literatura

Realizou-se revisão da literatura na base de dados do PubMed, utilizando o termo "necrose de medula óssea". Foram encontrados 25 artigos em inglês e 65 relatos de caso.

Resultados e discussão:

A fisiopatologia da NMO não é bem elucidada e parece estar associada a lesão vascular com consequente hipóxia celular por desbalanço na oferta de oxigênio e nutrientes. O fator de necrose tumoral alfa (TNF-α) provavelmente também está implicado na lesão endotelial e nos sinusoides da medula óssea. Sugere-se o diagnóstico pela presença de anemia, trombocitopenia, reação leucoeritroblástica, níveis elevados de desidrogenase lática e fosfatase alcalina. Aspirado e biópsia de medula óssea e ressonância nuclear magnética são os principais exames diagnósticos. As únicas possibilidades terapêuticas são tratamento da causa de base e medidas suportivas.

Conclusão:

O ponto mais importante no manejo da NMO é a busca por condições neoplásicas associadas.

Unitermos:
necrose de medula óssea; fator de necrose tumoral alfa; leucoeritroblástica; aspirado de medula óssea; biópsia de medula óssea

Variables	Paydas et al.⁽⁶6 Paydas S, Ergin M, Baslamisli F, et al. Bone marrow necrosis: clinicopathologic analysis of 20 cases and review of the literature. Am J Hematol. 2002; 70: 300-5.⁾	Katayama et al.⁽¹⁴14 Katayama Y. Bone marrow necrosis in a patient with acute myeloblastic leukemia during administration of G-CSF and rapid hematologic recovery after allotransplantation of peripheral blood stem cells. Am J Hematol. 1998; 57: 238-40.⁾	Godeau et al.⁽¹⁷17 Godeau B, Galacteros F, Schaeffer A, et al. Aplastic crisis due to extensive bone marrow necrosis and human parvovirus infection in sickle cell disease. JAMA. 1991; 91: 557-8.⁾	Chim et al.⁽⁹9 Chim CS, Lam CK, Wong KF, et al. Atypical blasts and bone marrow necrosis associated with near-triploid relapse of acute promyelocytic leukemia after arsenic trioxide treatment. Hum Pathol. 2002; 33: 849-51.⁾	Campiotti et al.⁽³3 Campiotti L, Codari R, Appio L, et al. Bone marrow necrosis related to imatinib mesylate therapy for CML bilateral blast crisis. Leuk Res. 2007; 31: 1765-72.⁾	Rossi et al.⁽¹²12 Rossi D, Ramponi A, Franceschetti S, Stratta P, Gaidano G. Bone marrow necrosis complicating post-transplant lymphoproliferative disorder: resolution with rituximab. Leuk Res. 2008; 32: 829-34.⁾	Lee et al.⁽¹¹11 Lee Y, Hong YC, Yang CF, et al. Severe extensive bone marrow necrosis from military tuberculosis without granulomas and pulmonary presentation. J Chin Med Assoc. 2010; 73: 208-11.⁾	Kumakura et al.⁽¹³13 Kumakura S, Ishikura H, Kobayashi S. Bone marrow necrosis and Lambert-Eaton syndrome associated with interferon alpha treatment. N Engl J Med. 1998; 338: 196-203.⁾	Azuma et al.⁽⁴4 Azuma T, Sakai I, Matsumoto T, et al. Leukemoid reaction in association with bone marrow necrosis due to metastatic prostate cancer. Intern Med. 2005; 44: 1093-6.⁾	Markovic et al.⁽¹⁰10 Markovic SN, Phyliky RL, Li CY. Pancytopenia due to bone marrow necrosis in acute myelogenous leukemia: role of reactive CD8 cells. Am J Hematol. 1998; 59: 74-8.⁾	Al-Gwaiz et al.⁽¹⁵15 Al-Gwaiz LA. Bone marrow necrosis. Ann Saudi Med. 1997; 17: 374-6.⁾	Bashawri et al.⁽⁷7 Bashawri L, Satti MB. Bone marrow necrosis: report of five cases and review of the literature. Ann Saudi Med. 2000; 20: 78-82.⁾	Ianotto et al.⁽¹⁸18 Ianotto JC, Tempescul A, Eveillard JR, Charles F, Berthou C. Non-lethal bone marrow necrosis under first line arsenic trioxide therapy in acute promyelocytic leukaemia. Acta Haematol. 2010; 123: 146-7.⁾	Lee et al.⁽⁵5 Lee JL, Lee JH, Kim MK, et al. A case of bone marrow necrosis with thrombotic thrombocytopenic purpura as a manifestation of occult colon cancer. Jpn J Clin Oncol. 2004; 34: 476-80.⁾	Invernizzi et al.⁽¹⁶16 Invernizzi R, D'Alessio A, Iannone AM, Pecci A, Bernuzzi S, Castelloal A. Bone marrow necrosis in acute lymphoblastic leukemia. Haematologica. 1995; 80: 572-3.⁾	Jain et al.⁽²2 Jain D, Singh T, Kumar N. Hypocellular acute myeloid leukemia with bone marrow necrosis in young patients: two case reports. J Med Case Rep. 2009; 3: 27-31.⁾	Khoshnaw et al.⁽¹⁹19 Khoshnaw NS, Al-Rawi HA, Nore BF. Precursor T-cell acute lymphoblastic leukemia presenting with bone marrow necrosis: a case report. J Med Case Rep. 2012; 6: 349-55.⁾	Aras et al.⁽²⁰20 Aras Y, Akakaya MO, Unal SN, Bilgic B, Unal OF. Bone marrow necrosis secondary do imatinib usage, mimicking spinal metastasis on magnetic resonance and FDG-PET/CT. J Neurosurg Spin. 2012; 16: 57-60.⁾	Khalil et al.⁽²¹21 Khalil YK, Pistoria MJ, Wright RE. Catastrophic antiphospholipid antibody syndrome with bone marrow necrosis: a rare complication. J Rheumatol. 2011; 38: 2279-81.⁾	Aydogdu et al.⁽²²22 Aydogdu I, Erkurt MA, Ozhan O, et al. Reversible bone marrow necrosis in a patient due to overdosage of diclofenac sodium. Am J Hematol. 2006; 81: 298-305.⁾	Ozkan et al.⁽²³23 Ozkan A, Ozkalemkas F, Ali R, Ozkocaman V, Ozelik T. Severe bone marrow necrosis without suggestive features. Am J Hematol. 2006; 81: 382-8.⁾	Vermeersch et al.⁽²⁴24 Vermeersch P, Zachee P, Brusselmans C. Acute myeloid leukemia with bone marrow necrosis and Charcot Leyden crystals. Am J Hematol. 2007; 82: 1029.⁾	Rossi et al.⁽²⁵25 Rossi P, Curiel M, Demoux AL et al. Bone marrow necrosis and sickle cell crisis associated with double heterozygosity for HbS and HbOARAB. Am J Hematol. 2010; 86: 309-10.⁾	Adamskii et al.⁽²⁶26 Adamski J, Hanna CA, Reddy VB, Litovsky SH, Evans CA, Marques MB. Multiorgan failure and bone marrow necrosis in three adults with sickle cell β+-thalassemia. Am J Hematol. 2012; 87: 621-4.⁾	Noguchi et al.⁽²⁷27 Noguchi M, Oshimi K. Extensive bone marrow necrosis and symptomatic hypercalcemia in B cell blastic transformation of chronic myeloid leukemia: report of a case and review of the literature. Acta Haematol. 2007; 118: 111-6.⁾	Total
n	20	1	1	1	1	1	1	1	1	1	16	5	1	1	1	1	1	1	1	1	1	1	1	3	1	65
Age (years)	15-65	38	24	39	67	67	66	41	80	70	5-80	26-57	53	67	67	32	10	67	40	26	19	66	39	25-53	66	5-80
M:F	13:7	1:0	0:1	0:1	1:0	1:0	0:1	1:0	1:0	1:0	10:6	3:2	1:0	1:0	1:0	0:1	1:0	0:1	0:1	1:0	1:0	1:0	1:0	3:0	1:0	44:21
Etiology
AML	3	1		1						1	2		1			1						1				11
ALL	1										7	2			1		1									12
NHL	4					1					1															6
HL	4										3									1						8
CML	2				1			1																	1	5
MDS/MPS	1																									1
Solid malignancy	3								1		2	1		1				1								9
AFS	1																		1							2
DIC				1									1													2
TTP														1												1
HbS			1																				1	3		5
TB	2						1																			2
Drugs	1	1			1			1				1	1					1		1						8
Unknown												2														2
Degree																										28
I	3															1										4
II	5																									5
III	12			1		1	1							1						1				2	1	19
Symptoms
Fever	⁺ + present;		⁺ + present;		⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;		⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	^- - absent;		⁺ + present;	⁺ + present;		⁺ + present;	⁺ + present;	⁺ + present;
Bone pain	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;		⁺ + present;	⁺ + present;	⁺ + present;			⁺ + present;		⁺ + present;	^- - absent;	⁺ + present;	⁺ + present;			⁺ + present;	⁺ + present;	⁺ + present;
Jaundice	⁺ + present;											⁺ + present;		⁺ + present;				^- - absent;					⁺ + present;
Laboratory
Anemia	⁺ + present;		⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;		⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;
Leucopenia	⁺ + present;	⁺ + present;		⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;			⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;		⁺ + present;			^- - absent;	^- - absent;	⁺ + present;	⁺ + present;	^- - absent;	^- - absent;	⁺ + present;	⁺ + present;
Thrombocytopenia	⁺ + present;			⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;			⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	^- - absent;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;	⁺ + present;
Leucoerythroblastic					⁺ + present;	⁺ + present;	⁺ + present;					⁺ + present;		⁺ + present;	⁺ + present;			^- - absent;						⁺ + present;
reaction
LDH	⁺ + present;				⁺ + present;	⁺ + present;			⁺ + present;		⁺ + present;	⁺ + present;		⁺ + present;	⁺ + present;			^- - absent;		⁺ + present;	^- - absent;		⁺ + present;	⁺ + present;	⁺ + present;
AF					⁺ + present;	⁺ + present;			⁺ + present;		⁺ + present;	⁺ + present;		⁺ + present;	⁺ + present;			^- - absent;		⁺ + present;	^- - absent;		⁺ + present;	⁺ + present;	⁺ + present;
Prognosis	10d-	70d	^¥ ¥ survival not achieved.	^† † premature death, without known time;	^¥ ¥ survival not achieved.	^¥ ¥ survival not achieved.	^¥ ¥ survival not achieved.	^¥ ¥ survival not achieved.	^¥ ¥ survival not achieved.	^¥ ¥ survival not achieved.	^- - absent;	20d - ^¥ ¥ survival not achieved.	^¥ ¥ survival not achieved.	^¥ ¥ survival not achieved.	120d	^- - absent;	6,5m	^¥ ¥ survival not achieved.	^¥ ¥ survival not achieved.	^¥ ¥ survival not achieved.	21d	^¥ ¥ survival not achieved.	^¥ ¥ survival not achieved.	^¥ ¥ survival not achieved.	2m
	22m
	(105,8d)

Disorder	Nº of patients
Malignant disorders	218
Hematologic malignancies	145
Acute leukemia	98
Acute lymphoblastic leukemia	43
Acute myeloid leukemia	31
Acute leukemia (not specified)	24
Myeloproliferative syndrome	13
Chronic myeloid leukemia	11
Essential thrombocythemia	1
Myelofibrosis	1
Lymphomas	35
Non-Hodgkin lymphoma	26
Chronic lymphocytic leukemia	2
Hairy cell leukemia	1
Multiple myeloma	1
Hodgkin disease	5
Solid tumors	72
Unspecified	34
Primary tumor of unknown origin	12
Stomach	14
Lung	3
Breast	1
Ovary	3
Prostate	1
Carcinoid	1
Kaposi	1
Esophagus	1
Neuroblastoma	2
Medulloblastoma	1
Non-malignant disorders	22
Infections	17
Sepsis	12
Pneumonia	1
Mucormycosis	1
Q fever	1
Tuberculosis	2
Parvovirus	4
HIV	1
Drugs	8
Sulfasalazine	1
Interferon-alpha	3
All-transretinoic acid	4
Fludarabine	1
Granulocyte-colony stimulating factor	1
Sickle-cell disease	6
Others	12
Hyperparathyroidism	1
Anorexia nervosa	1
Hemolytic uremic syndrome	1
Antiphospholipid syndrome	3
Disseminated intravascular coagulation	4
Idiopathic	2

BMN grade	Classification	Extent
I	Slight	< 20%
II	Moderate	20%-50%
III	Severe	> 50%

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[1] CORRESPONDING AUTHOR: Tamara Carvalho dos Santos Cabral, Rua Manoel Barreto, 324, apto 902; Graça; CEP: 40150-360; Salvador-BA, Brasil; e-mail: tamicarvalho@hotmail.com.