The “Mystique” of Acute Leukemia: MPAL-BAL-AUL-ALAL-aBLL-HAL-MLL : Initial presentation of MPAL as extramedullary neurological compromise; A case report and review of literature

Abstract

Abstract Introduction MPAL (Multi Phenotypic Acute Leukemia), BAL (Biphenotypic Acute Leukemia), AUL (Acute Undifferentiated Leukemia), ALAL (Acute Leukemia of Ambiguous Lineage), HAL (Hybrid Acute Leukemia), HAL (Hybrid Acute Leukemia), MLL (Mixed Lineage Leukemia) and aBLL (acute BiLineal Leukemia) represent different names of the same pathology or do these entities represent completely separate disease processes? These rather uncommon manifestations of acute leukemia complicate strict taxonomical sub grouping as well as their management. Rapid identification & swift management may restrict further neurological damage, while achieving hematological remission. Case description A 16 year female presented with gradual onset paraplegia for 7 months, a history of multiple blood transfusions in the past 2 years, pancytopenia, atypical cells in peripheral smear; the hematological and bone marrow work up revealed a diagnosis of: MPAL, B/Myeloid , NOS [Multi Phenotypic Acute Leukemia, B cell {lymphoid}/Myeloid, not otherwise specified]. An ALL type induction regimen was started. The management strategy, it's rationale and the clinical outcome are discussed. Conclusion For routine neurosurgical practice, these entities are extremely rare; and hence a working knowledge is very essential for appropriate & timely management notwithstanding the neurosurgical desire to rule out the compressive lesions first. Neurological status deterioration may be halted with timely institution of appropriate chemotherapy. In the extensive literature review in pubmed, this may be only the 1st case of MPAL with extramedullary neurological manifestation, at the first clinical presentation.