Acute Myeloid Leukemia and G6PD deficiency in a 47-year-old African American Male Patient with Suspected Gastrointestinal Bleed

Abstract

Background Anemia is three times more common in African Americans than in Caucasians. 90% of anemia can be attributed to nutritional deficiencies, chronic inflammation, or bleeding. In young male adults and both males and females above 65 years of age, chronic gastrointestinal loss is the most likely etiology of iron-deficiency anemia. However, malignancies (not limited to gastrointestinal malignancies) should be considered in the absence of obvious bleeding. Case Presentation We present a 47-year-old African American incarcerated male patient with a past medical history of hypertension and peptic ulcer disease who presented to our hospital with a 1-month history of nausea, vomiting, fatigue, and alleged two-day history of coffee-ground hematemesis. His hemoglobin had dropped by 5-6 g/dl over two months; red blood cell indices were suggestive of normocytic normochromic anemia. He also complained of dark urine and left flank pain. Gastrointestinal workup, including esophagogastroduodenoscopy and colonoscopy did not reveal an obvious bleeding source. During the hospital stay, his hemoglobin continued to decrease, and extensive anemia workup was ordered. Lactate dehydrogenase was elevated, reticulocyte count normal, haptoglobin level decreased, and a differential blood count revealed 55.7% “other abnormal cells.” The peripheral smear report revealed acute myeloid leukemia (AML), later confirmed by bone marrow biopsy, and the qualitative glucose-6-phosphate dehydrogenase (G6PD) screen was noted to be deficient. The patient was promptly started on induction chemotherapy for AML: cytarabine 100mg/m2 for 7 days, daunorubicin 90mg/m2 for 3 days, and midostaurin 50 mg twice daily from day 8-21. Discussion Acute myeloid leukemia (AML) can present with non-specific symptoms of anemia such as breathlessness, fatigue, and mucosal bleeding. It also commonly presents with fever and bone pain. Our patient’s history of peptic ulcer disease and initial complaints lead us to investigate gastrointestinal bleeding primarily. The concurrent diagnosis of G6PD in the setting of AML is significant since it has been reported to pose a higher risk for developing invasive fungal infections. From our experience, we recommend a broad approach to evaluating anemia, avoiding ascertainment bias, particularly in the African American population where anemia is more prevalent, and the etiology can be more variable.