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Bone Marrow Abnormality in a case of Chronic Myeloid Leukemia

Figure 1. Bone marrow aspirate smear (Giemsa stain) (1000x)

Govind Kendre, Shruti Mantri, Sunil Hilalpure, Suraj Goyanka, Leo Prince, Murlidharan C, Chandrakala S, Farah Jijina

Keywords : CML, sea-blue-histiocyte, bone marrow

Question:
An 11-year-old boy presented with fatigue for 4 months. There was no fever, breathlessness, weight loss, paleness, jaundice or bleeding from any site. On physical examination spleen was palpable 10 cm below left costal margin along its long axis. No other significant abnormality was detected. Complete blood count (CBC) revealed hemoglobin 10.5 g/dL, platelet count 179,000 cells/cumm, and white blood cell count 64,000 cells/cumm. Peripheral blood smear showed marked leukocytosis with left shift of granulocytes. Bone marrow smear examination showed hypercellular marrow and hypo-lobulated megakaryocytes with a differential count of erythroid precursors (10%), myelocytes and metamyelocytes (30%), band cells (30%), mature neutrophils (20%), myeloblasts (5%) and lymphocytes (5%). In the background of increased myeloid precursors, prominent macrophages were seen, the cytoplasm of which was closely packed with fine granules staining blue with Giemsa and the nuclei was displaced towards the periphery (Figure 1). Further investigations showed the presence of BCR-ABL1 fusion by fluorescent in situ hybridization, as well as by PCR, thus confirming the diagnosis of chronic myelogenous leukemia (CML).
What is the bone marrow aspirate smear suggestive of?