Relapsing acute myeloid leukaemia manifesting as uveitis with hypopyon

Abstract

A 5-year-old boy presented with a history of recurrent cough, lethargy and weight loss. On examination he had generalised lymphadenopathy, hepatosplenomegaly and bilateral pleural effusions. His full blood count at diagnosis was: haemoglobin 98 g/l, white cell count 138 × 109/l and platelet count 43 × 109/l. Bone marrow examination confirmed acute myeloid leukaemia and a cerebrospinal fluid cytospin was clear. Cytogenetic analysis showed 46,XY,der (1) t (1;1) (p36;q2?3) and trisomy 8. Pleural fluid aspirate was consistent with leukaemic infiltration. He was treated with chemotherapy, according to the protocol of the Acute Myeloid Leukaemia 15 trial, into which he was entered. He achieved complete morphological and cytogenetic remission post-induction phase. He re-presented with an 8-day history of left eye pain and low-grade temperature of 37·5°C. His full blood count was as follows: haemoglobin 119 g/l, white cell count 9·2 × 109/l and platelet count 268 × 109/l. He was prescribed neomycin eye ointment and oral cephalexin. He continued to deteriorate with worsening left eye symptoms, photophobia, lethargy and feeling generally unwell. He was reviewed by an ophthalmologist and was found to have an inflamed sclerae and marked inflammatory activity at the anterior chamber with a 2–3 mm hypopyon. He was re-examined under a general anaesthetic and was found to have corneal oedema of the left eye with a markedly thickened pale iris with dilated circumferential vessels; a clinical diagnosis of leukaemic infiltration of the iris was made (right and left panel). A diagnostic tap was felt to be unnecessary. A bone marrow aspirate and lumbar puncture were performed and confirmed bone marrow and central nervous system relapse. He was commenced on FLAG-I (fludarabine, cytarabine, idarubicin, granulocyte colony-stimulating factor) and weekly intrathecal chemotherapy. He had a further course of chemotherapy and underwent an allogeneic bone marrow transplantation. He engrafted but died <6 months later with extramedullary disease. Leukaemic hypopyon, as seen in this patient, is a rare manifestation of acute myeloid leukaemia.