Concurrent juvenile myelomonocytic leukemia with thalassemia in a case with Plasmodium knowlesi infection from Sabah, Malaysian Borneo.

Mimi Azreen Abdullah,Subbiah Vijay Kumar,Mohammad Zahirul Hoque,Saleh Mohammed Abdullah

doi:10.4081/hr.2019.8167

Abstract

A 3-year-old male child was presented with worsening abdominal pain, abdominal distension, lethargy, pallor and hepatosplenomegaly. The patient had multiple outpatient visits in the past and was treated with oral antibiotics, oral anthelmintic agents, albeit with minimal benefit. The patient also had non-neutropenic pyrexia spikes and oral ulcers. The patient was an adopted child; hence details about his biological parents’ previous history were unclear. Differential diagnosis of Chronic Myelomonocytic Leukemia (CMML), Juvenile Myelomonocytic Leukemia (JMML), Gaucher’s disease, Thalassemia and discrete pancreatic pathology was considered. Hemoglobin electrophoresis was indicative of thalassemia. Also, molecular detection method by polymerase chain reaction confirms a concurrent infection with Plasmodium knowlesi malaria. The BCR-ABL fusion gene was found to be negative. Correlating with peripheral monocytosis, bone marrow aspiration and trephine biopsy with blasts only 3-4% and hepatosplenomegaly, a diagnosis of JMML was established. We present a rare phenomenon with an overlap of signs and symptoms between JMML, underlying thalassemia, and Plasmodium knowlesi, posing a diagnostic challenge to physicians.

Highlights

We describe the findings from a child with the Juvenile myelomonocytic leukemia (JMML) syndrome with thalassemia with concurrent Plasmodium knowlesi infection
There was and viral infections can cause a response fered from an oral ulcer and was treated a presence of granulocytic precursors and called leukemoid reaction that can resemble with Gengigel (0.2% hyaluronic acid) topi- mature neutrophils in the intertrabecular the clinical symptoms of JMML
The nonspecific clinical findings early during this patient’s illness made it difficult initially to arrive at a specific diagnosis due to the concurrent occurrence of thalassemia, and Plasmodium knowlesi infection

Summary

Introduction

Juvenile myelomonocytic leukemia (JMML) is a lethal myeloproliferative disease (MPD) of young childhood and is characterized clinically by the overproduction. In addition to monocytic cell overproduction, patients are often present with anemia and thrombocytopenia. JMML patients can progress to blast crisis, usually with French-AmericanBritish (FAB) M4 or M5 morphology, but more frequently succumb to the disease due to tissue infiltration of myeloid cells.[5,6]. This case represents a rare diagnostic dilemma, as there is a considerable overlap of signs and symptoms between JMML with a hematologic phenotype of thalassemia and Plasmodium knowlesi infection. We describe the findings from a child with the JMML syndrome with thalassemia with concurrent Plasmodium knowlesi infection

Clinical findings

The child started to have multiple fever

Discussion

Findings

Hb E