3138 Unusual Gastrointestinal Petechial Bleeding of the Small Bowel Associated With Newly Diagnosed Chronic Myeloid Leukemia

Abstract

INTRODUCTION: Chronic myeloid leukemia (CML) often is diagnosed in the chronic phase based off routine laboratory analysis in asymptomatic patients with findings include splenomegaly, anemia, leukocytosis, and thrombocytosis. Patients less commonly present with bleeding due to platelet dysfunction. In the case presented, a patient presented with unusual petechial bleeding of the small bowel found on video capsule endoscopy (VCE) as the initial symptom of undiagnosed CML which is highly atypical. CASE DESCRIPTION/METHODS: A 79-year-old Caucasian male with a past medical history significant for atrial flutter status-post ablation (not on anti-coagulation) presented to the emergency room with maroon colored stools for 2 days with no other complaints. He denied abdominal pain, nausea, vomiting, or weight loss. Physical exam was benign with vital signs within normal limits. Laboratory analysis revealed white blood cell count of 84.9 t/cmm with 89.9% segmented neutrophils and hemoglobin (HGB) of 10.2 g/dL (previous HGB 14.4 g/dL). The patient was admitted for gastrointestinal (GI) bleeding and malignancy work up. HGB down trended to 7.7 g/dL and an esophagogastroduodenoscopy (EGD) was performed showing no abnormalities. Due to the continued drop in HGB, a colonoscopy was performed which showed old blood in the colon with no identifiable source of bleeding. VCE, interestingly, showed multiple clustered pinpoint petechiae in the ileum. Concurrently, it was suspected that the patient had underlying CML given absence of infection and findings of 1% blasts, basophilia, and eosinophilia. Bone marrow biopsy showed hypercellular bone with myeloid hyperplasia with FISH positive for BCR/ABL confirming CML. It was unknown if the VCE findings may have been related to the patient's newly diagnosed CML. DISCUSSION: Anemia is observed in about a third of the patients with newly diagnosed CML depending on the degree of tumor burden. Due to platelet dysfunction, patients may present with bleeding. Because of the significant HGB drop and melena, GI bleeding work up was initiated and ultimately identified a highly unusual source of bleeding. The VCE yielded unexpected images of petechial hemorrhage within the small bowel which was most likely secondary to the underlying malignancy. The case highlights the importance of ruling out sources of GI bleeding in the setting of severe anemia rather than anchoring on the diagnosis of CML. To our knowledge, these VCE findings have not been documented in CML.