Differential Diagnosis

Bone marrow failure syndromes are characterized by inadequate production of red cells, white cells, and platelets, leading to various combinations and severities of peripheral blood cytopenias. Typically, the bone marrow is hypocellular, as in this case, but a cellular bone marrow is encountered with clonal disorders including myelodysplastic syndrome, some acute leukemias and lymphomas, and paroxysmal nocturnal hemoglobinuria, secondary conditions such as bone marrow infiltration by metastatic cancer, sarcoidosis, or granulomas due to infections, and ineffective hematopoiesis due to longstanding folate or B12 deficiency.

The differential for pancytopenia and a hypocellular bone marrow includes constitutional and acquired aplastic anemia, starvation, hypothyroidism, and rarely, hematopoie-tic malignancies, most commonly myelodysplastic syndrome. Acquired aplastic anemia may be idiopathic or secondary to environmental toxins (benzene), radiation exposure, acute viral infection, or an idiosyncratic reaction to certain medications including nonster-oidal analgesics, antithyroid and psychotropic drugs, penicillamine, and gold salts. Finally, pancytopenia is a potential side effect of myelosuppressive chemotherapy agents. Based on the temporal association and the bone marrow findings, the diagnosis for this patient was azathioprine-induced bone marrow suppression.

Azathioprine therapy was immediately discontinued. He required many transfusions of red cells and platelets during his hospital stay. His blood cell counts slowly recovered with antibiotic, vitamin, granulocyte-monocyte colony stimulating factor, and erythropoietin therapies. He was discharged on hospital day 38.

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