Acute myelogenous leukaemia presenting as a conjunctival lesion and red eye

Abstract

Sir, Acute myelogenous leukaemia (AML) accounts for 1.2% of all cancer deaths. However, in contrast to other leukaemias, AML has only rarely been reported as causing ocular complications. Most ocular infiltrates from AML include chorioretinal or optic nerve lesions and are found incidentally in patients with advanced disease (Ells et al. 1995; Ghosh et al. 2000; Matano et al. 2000). To our knowledge, we report the first case of AML presenting with a conjunctival lesion, pathologically demonstrating the leukaemic infiltrate. A 42-year-old African American woman presented with complaints of a painful, red right eye. She had been in her usual state of health until approximately 2 days prior to admission, when she began to develop injection and severe photophobia in the right eye, preventing her from opening the eyelid. In the course of systemic evaluation, the subject also noted increased shortness of breath, back pain and multiple, erythematous leg lesions, all of which had begun in the past week. Her past medical history showed a clinical diagnosis of acute sarcoidosis made 15 months prior to this presentation. Ophthalmic examination revealed normal visual acuity and extraocular movement, but a sluggish right pupil. Marked scleral and conjunctival injection of the right eye was noted. A 3-mm white-tan, soft, mobile conjunctival lesion was located at the corneal limbus of the right eye. Mild iritis was also noted in the right eye. The left eye was normal and dilated fundus examination of both eyes was unremarkable. The right conjunctival lesion was biopsied and fixed for permanent histological specimens during the initial consultation as the patient had no previous biopsy evidence of sarcoidosis. Further systemic evaluation demonstrated multiple elevated, firm erythematous nodules on the subject's lower left leg, each measuring 1 cm in diameter. Her leucocyte count was 57 × 103/µL, with a high percentage of blasts, and her haemoglobin level was 9.2 g/dL, with platelets of 52 × 103/µL. The conjunctival biopsy showed infiltration with leukaemic cells consistent with myelogenous blasts (Fig. 1). Photomicrograph of the conjunctiva with extensive infiltration of myeloid blasts. (Haematoxylin-eosin, original magnification × 100.) Subsequent examination of the peripheral blood and bone marrow by flow cytometry was consistent with a large population of myeloblasts without monocytic features. Cytogenetic analysis revealed a t (6; 9) chromosome translocation. Taken together, these features were consistent with a diagnosis of acute myelogenous leukaemia (AML M2). A subsequent biopsy of the lesions on the patient's left leg also revealed blast cell infiltration. The patient underwent induction chemotherapy with idarubicin and ara C for 21 days. She experienced gradual haematopoietic recovery and was discharged 1 month after admission. Estimates of ophthalmic manifestations of leukaemia are varied. Schachat and colleagues examined 120 cases of AML and acute lymphotic leukaemia (ALL) at diagnosis, and reported leukaemic infiltrates in 3% of cases (Schachat et al. 1989). Most of these infiltrates were in the highly vascularized choroid, retina and optic nerve areas. The study also reported that 39% of cases had some ocular manifestation, but the findings were confined to the retina and optic nerve. Leukaemic infiltrates are uncommon in AML. In two prospective studies of 116 patients diagnosed with AML, none of the subjects were found to have leukaemic infiltrations in the eye (Karesh et al. 1989; Jackson et al. 1996). Acute myelogenous leukaemia uveitis is cited only in occasional case reports associated with advanced disease or central nervous system involvement. Occasional case reports describe a recurrence of AML associated with a hypopyon, choroidal infiltrate or optic nerve infiltration (Curto et al. 1989; Ells et al. 1995; Ghosh et al. 2000; Matano et al. 2000). One previous case reported a conjunctival lesion associated with acute myelomonocytic leukaemia cutis (Lee & Su 1985). This form of leukaemia is distinct from AML and is characterized by extensive skin involvement. To our knowledge, we report the first case of AML presenting with a conjunctival lesion, pathologically demonstrating the leukaemic infiltrate. This case underlines the importance of pathological diagnosis, especially when such biopsies can be performed in an office setting. As this case demonstrates, ocular signs and symptoms must be thoroughly considered when evaluating systemic disease.