The Role of Bone Marrow Aspiration in Diagnosis of Hypersplenism and other Diseases in Kassala Area Eastern Sudan, October 2016-October 2017

Introduction: Bone marrow aspiration (BMA) is an important tool in diagnosis of many haematological and non-haematological diseases. BMA usually done together with complete blood cell count (CBC) and peripheral blood picture. BMA needed for diagnosis of hypersplinsm. BMA alone is sufficient for diagnosis of megaloblastic anaemia, microcytic anaemia, acute leukaemia, chronic myeloid leukaemia, chronic lymphocytic leukaemia and immune thrombocytopenic purpura (ITP) . The objective of this study was to determine the indication of bone Aspiration (BMA) in Kassala state eastern Sudan. Identify the important of BMA in diagnosis of hyperslenism and other diseases in the area. Methodology: All cases for BMA referred from different hospitals and health centres in Kassala state. Seventy-one cases of bone marrow aspiration conducted at the Department of Pathology Faculty of Medicine, Kassala University from October 2016 to October 2017. Blood cell count and peripheral blood picture done for all patients subjected for bone marrow aspiration. Clinical information, physical examination, BMA results and other investigations recorded in specially designed form. Data entered on SPSS version 15 and statistically analyse. Results: In 71 of patients underwent BMA, 46 (64.8%) of them with splenomegaly. Twenty (44%) of patients with splenomegaly was due to bilharzia, 18 (39%) due to malaria, two due to malignancy (4%), two (4%) due Visceral Leishmaniosis and two unrevealed causes. Out of the cases with splenomegaly 34 (73.9%) showed features of hypersplenism. Non-splenomegaly cases, 8(32%), 3(12%), 2(8%), iron deficiency, haemolytic, aplastic, and megaloblastic anaemia respectively. 4 cases diagnosed as Idiopathic Thrombocytopenia (ITP). Two cases diagnosed as acute leukaemia. Conclusion: Bone marrow aspiration was very important tool for diagnosis of hypersplenism, endemic diseases in the area and other haematological disorders.


INTRODUCTION
Bone marrow aspiration (BMA) is an important tool in diagnosis of many haematological and non-haematological diseases. BMA usually done together with complete blood cell count (CBC) and peripheral blood picture. BMA needed for diagnosis of hypersplinsm. BMA alone is sufficient for diagnosis of megaloblastic anaemia,microcytic anaemia, acute leukaemia, chronic myeloid leukaemia, chronic lymphocytic leukaemia and immune thrombocytopenic purpura (ITP)(Bain BJ,Balaji JS2005, Chapman WC1999). BMA is important in diagnosis of Visceral Leishmaniasis (VL) and revealing Pyrexia of unknown origin (PUO) (Javier MD 2018). BMA in combination with bone marrow biopsy (BMB) help in diagnosis of granulomatous diseases, aplastic anaemia, myelodysplastic syndrome (MDS), myelofibrosis and metastatic solid tumours (Khan TA 2014). PMA play major role in establishing haematological abnormalities in patients with hepatosplenicschistosomiasis (HS) and portal hypertension (Luiz A 2013). Other liver diseases especially viral infections need BMB together with BMA to identify the pathological changes (Bushra A 2012). BMA is a costeffective safe diagnostic procedure in experienced hand when precautions considered. BMA used in recent cytogenetic and immune-phenotyping of many haematological malignancy (Bain BJ 2001). In this study, we determined the importance of bone marrow aspiration in diagnosis of hypersplenism among cases with splenomegaly. We also identify the indication of BMA and findings in Kassala area Eastern Sudan.

METHODOLOGY
This is a descriptive prospective study. All cases of bone marrow aspiration referred from hospitals, health centres and private clinics in Kassala and New Halfa area eastern Sudan from June 2017 to October 2018 included in this study. Before BMA: Request form checked. History completed. Thoroughly physical examination done. All these information put in specially designed form. Complete blood cell count and peripheral blood picture done. Any relevant investigations asked for in the request form and the blood kept if any further investigation needed. BMA: The procedure explained for the patient and verbal consent taken. Usually we choose the posterior superior iliac crest. In case of sacral oedema, recombinant and very obese we chose the anterior iliac crest. We take all universal infection precautions. The site cleaned with alcohol, infiltrated with local anaesthesia up to the periosteum and left for about 3 minutes. We aspirate about 0.25 ml and spread immediately on five microscopic slides. The slides, left to dry labelled and fixed with concentrated alcohol. One film stained with Gimsa stain, one stained by a Perl's stain (iron stain). Three films kept unstained. The films examined first by low power to assess cellularity, content of fragments and megakaryocyte number. Examined by X 40 objective to assess cytological detail of all lineages. X100 oil objective used to assess fine cytological details and Leishman Donovan body (LD body). The bone marrow aspiration report send to the clinician in special form. The important findings together with the peripheral blood film findings and others investigation results put in especial designed form for this study. We did not encounter severe complication a part from local pain. Few patients experienced bleeding stopped by pressing.

Statistical analysis
Data analysed using statistical Package for Social Science (SPSS). Pearson chi squared used to test for significance between proportions; p value below 0.5 considered statistically significant. We analysed the age, sex, indication for bone marrow aspiration findings,

Ethical Approval
An ethical clearance of the research obtained from combined Ethical Committee between Faculty of Medicine University of Kassala and Ministry of Health Kassala State. Oral consent taken from each patient.

BMA findings in patients with splenomegaly
Twenty (44%) of them with hepatosplenic schistosomiasis. 18 (39%) due to malaria. Two patients with chronic myeloid leukaemia (CML). Six (13%) of patients with splenomegaly the cause was not known (see Fig1).