CASE PRESENTATION
A 31-year-old Pakistani female presented with generalized body pain and
low back pain. Her past medical history was remarkable for
transfusion-dependent beta thalassemia (TDBT) major since childhood
complicated with iron overload as per her cardia and hepatic MRI
reports, receiving iron chelation therapy (Deferasirox 1080 mg daily),
type II diabetes mellitus on Insulin therapy and migraine. her past
surgical history includes splenectomy on 2012. She has a long history of
body pain. She was recently admitted due to COVID-19 infection and
discharged from quarantine facility one week earlier after a smooth
course of infection.
She presented to the emergency department complaining of body pain for
the last few days and dysuria. She has similar complains on and off for
many years, yet the pain increased recently, and it is mainly in the hip
and lower abdomen area (suprapubic), the pain increases with urination,
she has also back pain for the last three months more severe at night,
responds partially to analgesia, radiates to the hip and is limiting her
movement. On admission vitals were:
BP 107/67 mmHg,
HR 95/min
Temperature 36.7o
Saturation 96% on room air.
Primary investigations included: Labs, MRI pelvis and hips, Abdomen US
showed the following:
Labs: On admission:
Her labs revealed hypothyroidism, so she was started on Levothyroxine
therapy.
X ray pelvis and left hip:
Showed decreased bone density, bilateral coxa profunda.
US abdomen showed mildly enlarged fatty liver (18.2 cm).
US pelvic: Normal study.
MRI Hips and pelvic: Diffuse bone marrow reconversion and Presacral soft
tissue mass as described, most likely extramedullary hematopoiesis.
So as per MRI the patient has extramedullary hematopoiesis presenting as
soft tissue mass in the presacral area, from surgical point of view, the
mass is not accessible, but still need to be excised. After that
cervical and lumbar MRI spine was done to look if there are other
extramodular hematopoietic sites and it showed:
Diffusely decreased T1 marrow signal intensity of the entire visualized
bones which is in keeping with red marrow reconversion. Redemonstrations
of a presacral well defined lobulated soft tissue mass measuring 5.3 x 3
cm, it is separated from the underlying sacrum, no sacral destruction.
The mass is showing mild postcontrast enhancement suggestive of
extramedullary hematopoiesis. Another similar smaller extradural mass
measuring 2 cm is seen posterior to S1 vertebral body at the midline
laterally displacing S1 traversing nerve roots.
Currently: she is still on blood transfusion to keep HB more than 10 in
case of any surgical procedure was decided to be done, plan now is
toward the excision of the mass. The patient is taking the following
medications: Celecoxib 200 mg PRN, deferasirox 1080 mg oral daily,
insulin therapy and vitamin D supplementation, Levothyroxine 75 mg
daily, tramadol 50 mg oral BID.