Can tear drop cells be present in disease processes beyond bone marrow fibrosis?

Teardrop Cells in Disease Processes Beyond Bone Marrow Fibrosis

While teardrop cells are classically associated with bone marrow fibrosis, they are definitely present in several other disease processes including autoimmune hemolytic anemia, microangiopathic hemolytic anemia, and conditions with extramedullary hematopoiesis. 1, 2, 3

Conditions Associated with Teardrop Cells

Primary Conditions

• Myelofibrosis - The classic association where teardrop cells are most frequently observed 1
• Myelodysplastic Syndromes (MDS) - Teardrop cells are a sign of red cell dysplasia 1
• Infiltrative Bone Marrow Disorders:
  • Multiple myeloma with marrow fibrosis 4
  • Malignant infiltrative disorders of the bone marrow 2

Secondary Conditions

• Autoimmune Hemolytic Anemia (AIHA) - Present in 89% of cases in one study 2
• Microangiopathic Hemolytic Anemia (MAHA) - Present in 91% of cases in one study 2
• Conditions with Extramedullary Hematopoiesis - Particularly when associated with splenomegaly 3
• Systemic Conditions:
  • Lymphoma (may involve infiltration of bone marrow) 5
  • Sarcoidosis (can cause infiltration of hematopoietic tissues) 5
  • Hemochromatosis (can affect bone marrow function) 5
  • Amyloidosis (can infiltrate bone marrow) 5

Pathophysiological Mechanisms

The presence of teardrop cells in peripheral blood can occur through different mechanisms:

1. Altered Bone Marrow Architecture - The classic mechanism in myelofibrosis where fibrotic changes distort red cell production 1

2. Splenic Involvement - Extramedullary hematopoiesis and splenic sequestration can contribute to teardrop formation even without bone marrow fibrosis 3

   • Evidence shows that splenectomy or resolution of splenomegaly can lead to disappearance of teardrop cells in some cases 3

3. Red Cell Membrane Damage - In hemolytic anemias, damage to red cell membranes may contribute to teardrop formation 2

Clinical Significance and Evaluation

When teardrop cells are identified on peripheral blood smear, consider:

• Complete blood count to evaluate for cytopenias or other abnormal cell counts 1
• Peripheral blood smear examination for other red cell abnormalities, dysplastic features in granulocytes, and platelet abnormalities 1
• Bone marrow examination to evaluate cellularity, dysplasia, blast percentage, and fibrosis 1
• Molecular testing for mutations associated with myeloid disorders 1
• Evaluation for hemolytic processes if other findings suggest AIHA or MAHA 2

Important Caveats

• The presence of teardrop cells should always prompt consideration of bone marrow examination, but the differential diagnosis should be broadened beyond just myelofibrosis 1
• Teardrop poikilocytosis can be reversible with effective treatment of the underlying condition 6
• The prevalence of teardrop cells in hemolytic anemias is significantly higher than previously recognized 2
• When teardrop cells are present with splenomegaly but without bone marrow fibrosis, consider autoimmune processes or extramedullary hematopoiesis 3

Remember that while teardrop cells are a valuable diagnostic clue, they must be interpreted in the context of other clinical and laboratory findings to determine the underlying pathology.