Case Report

Bone Marrow Granuloma in Typhoid Fever: A Morphological Approach and Literature Review

Table 1

Typhoid granuloma: a brief review of the literature.

Author, year, ReferenceNumber of cases ()Age (years)/genderSitePathologyMicrobiologyRemarks

Shin et al. [3], 20041620–56,
male : female = 7 : 8
Bone marrow8/16: chronic granulomatous inflammation (4: well-formed, 4: ill-formed)
4/16: HLH
4/16: reactive marrow
2/16: myeloid hyperplasia
2/16: nonspecific
Erythrophagocytosis +
Phagocytosis of the debris +
Salmonella typhi  
Culture proven (100%)
Early phase: myeloid hyperplasia
Proliferative phase-histiocytic hyperplasia, granulomas, and erythrophagocytosis +
Lysis phase: well-formed granulomas with erythrophagocytosis +.

Young et al. [4], 19866010–60Bone marrowTyphoid cells: 50.8% in BMA;
8/49: granulomas on BMBx (4/8: typhoid cells +)
Type of BMG:
6/8: mature histiocytic granuloma, 2/8: epithelioid granuloma
Granuloma number:
One in 4, two in 3, and four in one
Salmonella typhi
34/60: bacteriologically
proven; 10/60: serologically proven; 16/60: clinically suspected
No specific morphology of BMG, BMA culture: high yield

Lee et al. [5], 198527Bone marrowWell-formed granuloma (57%), ill formed granuloma (43%)
Phagocytosis of nuclear debris, RBCs; ++. No caseation or Langhans giant cells
Salmonella typhi
Culture proven (100%)
Histiocytic phagocytosis, absence of necrosis and Langhans giant cells, clue to diagnosis of typhoid granulomas

Sakhalkar et al. [6], 200112, child with Down syndromeBone marrowFever, pancytopenia, hepatomegaly, hemophagocytosis, BMGSalmonella typhi
Culture (BMA and blood)
EBV positive, Salmonella typhi  +

Mert et al. [7], 2004 255, femalesLiver and spleenBMA, NAD
Noncaseating granulomas
Salmonella typhi
(blood)
1st case of typhoid splenic granuloma in the English literature.
66, malesBone marrow and liver2 granulomas in BMBx
(noncaseating)
1 microgranuloma in portal region
Salmonella typhi
Serology
Culture (blood, BMA)

Lee et al. [8], 2004134, malesBone marrowFocal epithelioid granuloma
Necrotic debris, phagocytosis not seen
Salmonella paratyphi A Culture (blood and BMA) Serology (typhi H); + (1 : 320)

Bharadwaj et al. [9], 2009 147, malesTerminal ileum, mesenteric lymph nodeNecrotizing and nonnecrotizing epithelioid granulomas, giant cells present
Lymphoerythrophagocytosis + (occasional)
Salmonella typhi
Serology

Present case 2013124, maleBone marrowWell-formed noncaseating granulomas (histiocytic and epithelioid type) Erythrophagocytosis ++Salmonella typhi
Serology
Culture (BMA, blood)
Erythrophagocytosis is a clue to the diagnosis of typhoid granulomas

HLH: hemophagocytic lymphohistiocytosis, +: present, BMA: bone marrow aspiration, BMBx: bone marrow trephine biopsy, BMG: bone marrow granuloma, EBV: Epstein-Barr virus; NAD: no abnormality detected.