Article Type : Case Report
Authors : Georgescu GD
Keywords : Acute leukemia is a clonal; Abnormal blast cells; Bone marrow
Acute leukemia is a clonal, malignant disease characterized by the
accumulation of abnormal blast cells, mainly in the bone marrow, and inhibition
of normal hematopoiesis. Acute leukemia is a pathology that requires emergency
diagnosis and can be associated with a poor prognosis. Objectives and Methods:
There will be presented 6 cases of acute leukemia with associated pathology,
with unfavorable prognosis. Results: There were 5 female with acute myeloid
leukemia and 1 male patient with acute with acute lymphoblastic B cell
leukemia hospitalized in the Colentina
Clinical Hospital during years 2021-2022 with very poor outcome.The data were
collected from the general clinical observation papers, with the consent of the
patients. Conclusion: Acute leukemia is a high-risk malignancy that can be
associated with other conditions which influence the patient’s outcome.
Acute leukemia is a
clonal, malignant disease characterized by the accumulation of abnormal blast
cells, mainly in the bone marrow, and inhibition of normal hematopoiesis [1].
Acute leukemia is a pathology that requires emergency diagnosis and can be
associated with a poor prognosis.
There will be
presented 6 cases of acute leukemia with associated pathology, with unfavorable
prognosis.The data were collected from the general clinical observation papers,
with the consent of the patients.
Case 1
The 38-year-old
female with no medical history came to Emergency Room in December 2021 for
headache and right hemicranias.
Investigations show:
•
CBC: WBC-148150/mmc, Mo- 127560/mmc, Hb- 7g/dL, Platelets- 25000/mmc
•
Fibrinogen -122 mg/dL, D-dimeri >20(VN-0-0.5 mcg/ml)
•
PBS: Atypical promyelocytes: 93%
•
Bone marrow aspirate: hypercellularity with 90% atypical promyelocytes
•
Immunophenotype: Acute Promyelocytic Leukemia (APL)
•
FISH: t(15;17) in 94% from the analyzed nuclei
•
PML RARA- positive
•
Cardiac ultrasound: left ventricular ejection fraction - 60%
•
CT cerebral: left frontal hemorrhagic stroke of ~28mm with cytotoxic
edema, without mass effect on the midline and without intraventricular break-in
Diagnosis was with
acute promyelocytic leukemia (APL) high risk, for which chemotherapy was
initiated - treatment: ATRA+Idarubicine and Dexamethasone prophylaxis for ATRA
syndrome [2,3]. On Day 3 ot treatment: the patient presents temporo-spatial
disorientation, desaturation and right upper limb hemiparesis. She installs a
coma (GCS 5 points) and requires admission to the ICU. Cerebral CT scan show
significant extension of the left frontal hemorrhage, with significant
displacement of the median line to the right, as well as the new cerebellar.
On Day 5 ot treatment Emergency decompression
neurosurgery was performed, which revealed a ruptured arterio-venous
malformation, which led to death. Diagnosis was: bleeding arterio-venous
malformation and multiple cortico-subcortical arterio-venous malformations.
Case 2
A 38-year-old female,
with grade III obesity and left upper limb venous thrombosis in March 2022 came
to Emergency Room.
Investigations show:
•
CBC: WBC-174080/mmc,Mo-142300/mmc, Hb-7 g/dl, Platelets-18000/mmc
•
LDH - 1140U/L, CRP- 99 mg/L
•
D-Dimeri 9.95 mcg/mL, Fibrinogen - 426 mg/dL
•
PBS: 90% blasts
•
Bone marrow aspirate: >90% blasts (suggestive of myeloblasts and
monocytoid blasts)
•
Immunophenotype: Acute myelomonocytic leukemia with co-expression of B
lymphocyte markers [4]
•
Cytogenetic: normal karyotype
•
FLT3 TKD positive [5]
•
Cardiac ultrasound: left ventricular ejection fraction – 60%
•
Venous doppler ultrasound of the left upper limb: Superficial venous
thrombosis left cephalic vein
•
CT scan: Segmental and subsegmental pulmonary thromboembolism. Splenic
infarction
Diagnosis was acute
myelomonocytic leukemia FLT3 TKD positive - hyperleukocytic form (High risk AML
M4 FAB) for which standard induction protocol, 3+7, and FLT3 inhibitor
(Midostaurin) was initiated [6].
Since the patient
associated left cephalic vein thrombosis, complicated with PE in the segmental
and subsegmental arteries, splenic infarction, bilateral central retinal vein
thrombosis - hemorrhagic form and subsequent cerebellar hemorrhagic stroke, the
outcome was poor. CT scan show Cerebellar hemorrhagic stroke, with cytotoxic
edema, causing a mass effect on the IV ventricle, which led to death.
Case 3
A 44-year-old
patient, chronic ethanol user and smoker, came to Emergency Room in June 2022
for cutaneous petesial purpura.
Investigations show:
•
CBC: WBC -400/mmc, Neu-100/mmc, Hb-4,9 g/dl , Platelets-1000/mmc
•
CRP - 246mg/L, ALT - 224 U/L, AST - 22 UI/L, PCT-0.36 ng/mL, uric acid –
18.36 mg/dl
•
Ac anti EBV and CMV IgM – negative
•
Fibrinogen - 568 mg/dl, D-Dimeri-1.67 mg/ml
•
PBS: 3% blasts
•
Bone marrow aspirate: 90% blasts with a round nucleus, finely
structured, with basophilic cytoplasm, without granulations
•
Immunophenotype: B cell Acute lymphoblastic leukemia [7]
•
Cardiac ultrasound: left ventricular ejection fraction – 60%
Diagnosis was acute
lymphoblastic B cell leukemia, with severe pancytopenia for whom specific
chemotherapeutic treatment was initiated: start protocol GRALL 2003. [8].
During post-chemotherapy aplasia presented sepsis with positive blood cultures
for E. coli and Candida Tropicalis, with unfortunate evolution, despite the
broad-spectrum antibiotic and antifungal treatment. He installs a coma (GCS 5
points) and requires admission to the ICU, Oro-tracheal intubation and
mechanical ventilation and exitus.
Case 4
A 66-year-old female,
with no significant medical history, diagnosed in February 2020 with acute
myelomonocytic leukemia secondary after CMMoL [9].
Investigations show:
•
CBC: WBC - 47170/mmc,
Mo-25000/mmc, Hb-10 g/dl, Platelets-15000/mmc
•
LDH-390 U/L
•
PBS: 18 % blasts, myelocytes 14%, metamyelocytes -10%, Mo-10%
•
Bone marrow aspirate: 10% myeloblasts, 13% atypical monocytes,
erythroblastopenia
•
Immunophenotype: 13 % myeloblasts and 26% monocytoid infiltrates
•
Bone marrow biopsy: Transformed chronic myelo-monocytic leukemia (CMMoL)
•
Cytogenetic: trisomy 10 and 11
•
FLT3 negative
•
Cardiac ultrasound: left ventricular ejection fraction – 50%
Diagnosis was AML M 5
FAB post CMMoL, for which therapy with hypomethylating agent was administered
[10]. In July 2020, the bone marrow biopsy reveals diagnosis of AML M 5 FAB
post CMMoL and a BCL2 inhibitor was added to Azacitidine therapy [11]. The
patient had initial favorable response to treatment, but with complications:
neutropenia and thrombocytopenia and in December 2021 - Bronchopneumonia. In
January 2022, the patient associated SARCOV2 infection treated with Remdesivir
treatment [12,13]. But severe neutropenia and thrombocytopenia with severe GI
bleeding led to death.
Case 5
A 64-year-old female,
with obesity gr II and type 2 Diabetes, was initially diagnosed in 2011 with
MDS-RAEB2, for whom she received treatment with a hypomethylating agent, with a
partial hematological response, with persistent thrombocytopenia [14,15].
In June 2022, the
patient was hospitalized with extensive cutaneous mucosal hemorrhagic syndrome.
Investigations
revealed:
•
CBC: WBC 129710/mmc, Mo-74300/mmc, Hb-6.1g/dL, Platelets-11000/mmc
•
PBS: Monoblasts – 50%
•
Bone marrow aspirate– 70% blasts/ atypical monocytes
•
Immunophenotype: Acute Monoblastic Leukemia
•
FLT3 ITD + positive
•
Cytogenetic: Del 11q
Diagnosis was
transformation into acute leukemia - AML FAB M4 with hyperleukocytosis, high
risk, with the presence of Del (11) (q23) and positive FLT3 ITD mutation
[16]. During evolution, the patient
installs cerebellar hemorrhagic stroke, which led to death.
Case 6
A 54-year-old female,
known with Spondylitis on immunosuppressive treatment, came to Emergency Room
in December 2021 for pain right ankle and profuse perspiration.
Investigations
revealed:
•
CBC: WBC 2800/mmc, Hb-9.5g/dL, Platelets- 250000/mmc
•
CRP-209 mg/L, PCT- 0.39 ng/mL
•
D-Dimeri 2.27 mcg/ml, Fibrinogen- 607 mg/dL
•
PBS: blasts- 10%
•
Bone marrow aspirate: >80% blasts with a round nucleus, rare
nucleoli, a lot of cytoplasm, blue, without granulations
•
Immunophenotype: AML secundary post MDS
•
Bone marrow biopsy: AML M2 FAB
•
Cytogenetic: complex karyotype: hipo diploidia, del 8q
•
FLT3 ITD negative
•
Cardiac ultrasound: left ventricular ejection fraction – 55%
•
CT scan: Hepatomegaly; hepatic hemangioma
Diagnosis was acute
myeloblastic leukemia - High risk AML M2 FAB, post myelodysplastic syndrome,
for which standard induction protocol, 3+7” was initiated, followed by period
of severe aplasia, during which she presents SEPSIS, Clostridium Difficile
infection, SARS-COV2 infection, positive blood cultures with E. Coli for which
she received broad-spectrum antibiotic treatment and antiviral treatment. Due
to severe thrombocytopenia, the patient has severe GI bleeding. During the
hospitalization the patient also presented an internal jugular vein thrombosis
associated with the insertion of the central venous catheter. The patient's
evolution was unfavourable. She installs a coma (GCS 5 points) and requires
admission to the ICU, Oro-tracheal intubation and mechanical ventilation and
exitus [17].
Acute leukemia is a
high-risk malignancy that can be associated with other conditions which
influence the patient’s outcome, despite current therapeutic advances.