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A "bone marrow score" for predicting hematological disease in immunocompetent patients with fevers of unknown origin
Hao-Yuan Wang1, Ching-Fen Yang, Tzeon-Jye Chiou
1From the Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (H-YW, J-PG, Y-BY, C-YL, J-HL, P-MC, H-CH, C-HT, L-TH); Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan (H-YW, C-FY, T-JC, S-HY, J-PG, Y-BY, C-YL, J-HL, P-MC, H-CH, C-PF, C-HT, L-TH); Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (C-FY); Division of Transfusion Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (T-JC); Division of Oncology and Hematology, Department of Medicine, National Yang-Ming University Hospital, Yilan, Taiwan (S-HY); Division of General Medicine, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (H-CH); and Division of Infectious Disease, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan (C-PF).
Abstract:
Delayed diagnosis of hematological malignancies in immunocompetent patients with fever of unknown origin (FUO) remains an exhausting challenge for non-hematologist physicians. This retrospective cohort study aimed to establish a scoring system, "bone marrow (BM) score", to identify FUO patients who require early bone marrow biopsy (BMB) to diagnose hematological disease. Two cohorts, comprising 85 (training) and 20 (validation) eligible immunocompetent patients, with FUOs diagnosed between January 1, 2006 and July 31, 2013, underwent BMBs and were enrolled in the study. Demographic, laboratory, imaging, diagnostic, and outcome data were collected and retrospectively analyzed. Factors associated with hematological etiologies diagnosed using BMBs in the training cohort were identified and scored according to the relative hazards. These were further validated using the validation cohort. For the training cohort, 29 of 85 (34.1%) patients had hematological etiologies diagnosed using BMB. Seven factors significantly predicted the diagnostic yield of hematological diseases in the BM and were scored, with the 6 points for leucoerythroblastic changes in peripheral blood smears, 5.5 for elevated ferritin level (>1000 ng/mL), 4 for splenomegaly, 2 for thrombocytopenia, 1.5 for each of elevated lactate dehydrogenase levels and anemia, and 1 for neutropenia. When the cut-off value of the scoring system was set to 6, its sensitivity and specificity to diagnose hematological diseases in the BM of immunocompetent FUO patients were 93% and 58%, respectively. For the validation cohort, 7 of 20 (35%) patients had hematological disease, and all had BM scores higher than the cut-off, with the sensitivity and specificity at 100% and 77%, respectively. As immunocompetent FUO patients with hematological disease have poor prognoses, the "BM score" is valuable for non-hematologist physicians to identify immunocompetent FUO patients requiring early BMB.
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