Fulminant hepatitis B following rituximab therapy in a patient with Evans syndrome and large B‐cell lymphoma

Reversible Bone Marrow Necrosis in a Patient Due to Overdosage of Diclofenac SodiumTo the Editor: Bone marrow necrosis (BMN) is a rare disease, and approximately 270 cases with BMN have been reported in literature up to now [1].Although malignant hematopoietic diseases are common causes of BMN, benign diseases and drugs including interferon alpha, fludarabine, and paracetamol may be the nonmalignant causes of this pathology [1-3].There are no reported cases of BMN due to diclofenac in literature.We present a patient with reversible BMN due to overdose consumption of diclofenac sodium because of renal colic.A 26-year-old male was suffering from symptoms of anemia, fever, and bone pain.He had nephrocalcinosis and was treated with diclofenac because of renal pain.Diclofenac was used intramuscularly for renal colic in a dose of 75 mg repeatedly with 30-min intervals for 12 doses.He experienced fever and bone pain 5 days after diclofenac administration.Physical examination revealed fever and pallor of skin.Remarkable laboratory findings were hemoglobin level (7.7 g/dL), leucopenia (1.6 Â 10 9 /L), neutropenia (0.5 Â 10 9 /L), and no thrombocytopenia (179 Â 10 9 /L).His biochemical profile revealed high levels of alkaline phosphatase (AP) 940 IU/L (normal range, 60-300 IU/L) and lactate dehydrogenase (LDH) 520 IU/L (normal range, 220-450 IU/L).Bone marrow aspiration smears showed striking necrosis and nearly absent intact hematopoietic cells, whereas bone marrow biopsy revealed BMN (100%; Fig. 1), which was graded according to the extent of necrosis in the BM biopsy described by Maisel et al. [4].Red blood cells were transfused because of symptomatic anemia.Two months later, his physical examination and laboratory results were resolved.Nine months after his initial admission, his physical examination was normal.Diclofenac is a pain reliever and an anti-inflammatory drug that is usually used as an analgesic in rheumatologic diseases and in general practice.Common adverse effects of diclofenac include gastrointestinal symptoms, peptic ulcus, and bleeding.Although it is usually administered at 75-150 mg daily, diclofenac was given to the patient described herein at a total dose of 900 mg/day.BMN is characterized by necrosis of the medullary stroma and myeloid tissues in large areas of the bone marrow, probably because of failure of the microcirculation.Toxic effects of chemotherapy, microvascular infarction, tumor necrosis factor, and thrombosis were blamed for the pathophysiology of BMN [1].We believe that BMN in our patient may be due to the inflammation created by the cytokine release because of overdosed diclofenac.Although the prognosis of patients with BMN is usually poor, diseases causing BMN and the age and grade of the necrosis are the main indicators of prognosis [5].In our case, he was young and had no other diseases.In conclusion, BMN is a rare clinical condition.It should be kept in mind that some patients may have reversible BMN due to drugs and benign diseases.