PLEURAL EFFUSION AS AN INITIAL PRESENTATION OF EXTRAMEDULLARY ACUTE MYELOID LEUKEMIA: A RARE PHENOMENON

Abstract

SESSION TITLE: Problems in the Pleura Case Posters 2SESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: Extramedullary acute myeloid leukemia (AML) or myeloid sarcoma is a rare occurrence. More rare is the presentation of the disease with pleural effusion as the initial presenting symptom. Less than 35 cases have been reported in the literature.CASE PRESENTATION: An 87-year-old female with past medical history of venous thromboembolic disease receiving anticoagulation presented with a one-week history of pleuritic chest pain and dyspnea. On presentation, she was tachycardic and tachypneic. CBC, CMP, BNP and Troponin were unremarkable. CT chest with IV contrast of the patient revealed a large loculated right pleural effusion, small left pleural effusion, and a soft tissue mass in the lower posterior mediastinum encircling the aorta and partially enveloping the vertebrae at T11-T12 to involve the neural foramina. Of note, a 2-month older CT scan revealed no such findings. MRI spine showed an abnormal marrow signal involving the T9-T12 vertebrae, with bilateral pleural effusion and a soft tissue mass similar to that seen on CT scan. A chest tube was placed on the right side, and pleural fluid was sent for culture and cytology. The patient also underwent biopsy of the mediastinal mass. Pleural fluid analysis revealed exudative fluid and negative infectious evaluation; flow cytometry of the pleural fluid was significant for an abnormal cellular population, immunophenotypically consistent with myeloblast. Cytogenetics was negative for common myeloid abnormalities. Histopathology of posterior mediastinal mass was consistent with myeloid neoplasm. Subsequent bone marrow biopsy, however, did not reveal marrow involvement. Thus, a corroborative diagnosis of extramedullary AML was made. She was soon started on induction chemotherapy. The chest tube was withdrawn following the resolution of right-sided effusion. The patient was discharged upon improvement in bilateral pleural effusion and completion of induction chemotherapy.DISCUSSION: Pleural effusions associated with hematologic malignancy are most commonly due to Hodgkin and non-Hodgkin lymphoma. Pleural effusions are rarely observed in patients with leukemia and even less frequently among those with AML. AML usually presents with blood dyscrasia and symptoms related to complications of pancytopenia. Extramedullary AML is a rare manifestation characterized by the presence of leukemic cell aggregates in an extramedullary site. More research is needed to determine the prognostic value of leukemic pleural effusions, along with the efficacy and safety of emerging targeted medications.CONCLUSIONS: This case highlights the rare possibility of pleural effusion as a manifestation of extramedullary AML, emphasizing the importance of the biochemical analysis, flow cytometry and the cytopathology of pleural fluid specimen. This is also helpful in early detection to guide effective therapy without delay.Reference #1: Wang ST, Chen CL, Liang SH, Yeh SP, Cheng WC. Acute myeloid leukemia with leukemic pleural effusion and high levels of pleural adenosine deaminase: A case report and review of literature. Open Med (Wars). 2021;16:387-396. doi:10.1515/med-2021-0243Reference #2: Pemmaraju N, Chang E, Daver N, et al. Extramedullary acute myeloid leukemia: leukemic pleural effusion, case report and review of the literature. Front Oncol. 2014;4:130. doi:10.3389/fonc.2014.00130Reference #3: Duhan A, Kalra R, Kamra HT, et al. Leukaemic pleural effusion as a manifestation of acute myeloid leukaemia: a case report and review of literature. Ecancermedicalscience. 2014;8:397. doi:10.3332/ecancer.2014.397DISCLOSURES: No relevant relationships by Qiraat AzeemNo relevant relationships by Dua AzimNo relevant relationships Added 03/27/2022 by Cynthia Brown, value=Consulting feeRemoved 03/27/2022 by Cynthia BrownNo relevant relationships Added 03/27/2022 by Cynthia Brown, value=Grant/Research SupportRemoved 03/27/2022 by Cynthia BrownNo relevant relationships Added 03/27/2022 by Cynthia Brown, value=Grant/Research SupportRemoved 03/27/2022 by Cynthia BrownNo relevant relationships Added 03/27/2022 by Cynthia Brown, value=Grant/Research SupportRemoved 03/27/2022 by Cynthia BrownNo relevant relationships Added 03/27/2022 by Cynthia Brown, value=Grant/Research SupportRemoved 03/27/2022 by Cynthia BrownNo relevant relationships Added 03/27/2022 by Cynthia Brown, value=Grant/Research SupportRemoved 03/27/2022 by Cynthia BrownNo relevant relationships by Sasmith Menakuru SESSION TITLE: Problems in the Pleura Case Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Extramedullary acute myeloid leukemia (AML) or myeloid sarcoma is a rare occurrence. More rare is the presentation of the disease with pleural effusion as the initial presenting symptom. Less than 35 cases have been reported in the literature. CASE PRESENTATION: An 87-year-old female with past medical history of venous thromboembolic disease receiving anticoagulation presented with a one-week history of pleuritic chest pain and dyspnea. On presentation, she was tachycardic and tachypneic. CBC, CMP, BNP and Troponin were unremarkable. CT chest with IV contrast of the patient revealed a large loculated right pleural effusion, small left pleural effusion, and a soft tissue mass in the lower posterior mediastinum encircling the aorta and partially enveloping the vertebrae at T11-T12 to involve the neural foramina. Of note, a 2-month older CT scan revealed no such findings. MRI spine showed an abnormal marrow signal involving the T9-T12 vertebrae, with bilateral pleural effusion and a soft tissue mass similar to that seen on CT scan. A chest tube was placed on the right side, and pleural fluid was sent for culture and cytology. The patient also underwent biopsy of the mediastinal mass. Pleural fluid analysis revealed exudative fluid and negative infectious evaluation; flow cytometry of the pleural fluid was significant for an abnormal cellular population, immunophenotypically consistent with myeloblast. Cytogenetics was negative for common myeloid abnormalities. Histopathology of posterior mediastinal mass was consistent with myeloid neoplasm. Subsequent bone marrow biopsy, however, did not reveal marrow involvement. Thus, a corroborative diagnosis of extramedullary AML was made. She was soon started on induction chemotherapy. The chest tube was withdrawn following the resolution of right-sided effusion. The patient was discharged upon improvement in bilateral pleural effusion and completion of induction chemotherapy. DISCUSSION: Pleural effusions associated with hematologic malignancy are most commonly due to Hodgkin and non-Hodgkin lymphoma. Pleural effusions are rarely observed in patients with leukemia and even less frequently among those with AML. AML usually presents with blood dyscrasia and symptoms related to complications of pancytopenia. Extramedullary AML is a rare manifestation characterized by the presence of leukemic cell aggregates in an extramedullary site. More research is needed to determine the prognostic value of leukemic pleural effusions, along with the efficacy and safety of emerging targeted medications. CONCLUSIONS: This case highlights the rare possibility of pleural effusion as a manifestation of extramedullary AML, emphasizing the importance of the biochemical analysis, flow cytometry and the cytopathology of pleural fluid specimen. This is also helpful in early detection to guide effective therapy without delay. Reference #1: Wang ST, Chen CL, Liang SH, Yeh SP, Cheng WC. Acute myeloid leukemia with leukemic pleural effusion and high levels of pleural adenosine deaminase: A case report and review of literature. Open Med (Wars). 2021;16:387-396. doi:10.1515/med-2021-0243 Reference #2: Pemmaraju N, Chang E, Daver N, et al. Extramedullary acute myeloid leukemia: leukemic pleural effusion, case report and review of the literature. Front Oncol. 2014;4:130. doi:10.3389/fonc.2014.00130 Reference #3: Duhan A, Kalra R, Kamra HT, et al. Leukaemic pleural effusion as a manifestation of acute myeloid leukaemia: a case report and review of literature. Ecancermedicalscience. 2014;8:397. doi:10.3332/ecancer.2014.397 DISCLOSURES: No relevant relationships by Qiraat Azeem No relevant relationships by Dua Azim No relevant relationships Added 03/27/2022 by Cynthia Brown, value=Consulting fee Removed 03/27/2022 by Cynthia Brown No relevant relationships Added 03/27/2022 by Cynthia Brown, value=Grant/Research Support Removed 03/27/2022 by Cynthia Brown No relevant relationships Added 03/27/2022 by Cynthia Brown, value=Grant/Research Support Removed 03/27/2022 by Cynthia Brown No relevant relationships Added 03/27/2022 by Cynthia Brown, value=Grant/Research Support Removed 03/27/2022 by Cynthia Brown No relevant relationships Added 03/27/2022 by Cynthia Brown, value=Grant/Research Support Removed 03/27/2022 by Cynthia Brown No relevant relationships Added 03/27/2022 by Cynthia Brown, value=Grant/Research Support Removed 03/27/2022 by Cynthia Brown No relevant relationships by Sasmith Menakuru