Acute Leukemia Presenting Research Articles

Galactorrhea and Acute Lymphoblastic T-Cell Leukemia: A Case Presentation and Evaluation of the Role of Prolactin

AbstractAbstract 4828Acute lymphoblastic T-cell leukemia (T-ALL) accounts for nearly 15% of newly diagnosed cases of childhood acute lymphoblastic leukemia (ALL). Historically, T-ALL has conferred a worse prognosis than other forms of ALL. Although multi-agent pulse chemotherapy has improved EFS over the past several decades, the lack of clinical or laboratory based prognosticators as well as high rate of relapse have remained barriers in management. Described is a case of acute lymphoblastic T-cell leukemia in a previously healthy sixteen-year-old girl initially presenting with galactorrhea and hyperprolactinemia without evidence of CNS infiltrate. Although galactorrhea has been described in a few adults as an initial presentation of acute myeloginous leukemia (AML) and a single adult case of T-cell lymphoma, to date there has been no association with childhood cancers or T-ALL in particular. Hypothesized in AML cases as a rare paraneoplastic phenomenon, this case explores this theory and employs direct prolactin staining of tumor cell cytoplasm, serial prolactin monitoring throughout treatment, and investigation into underlying causes for hyperprolactinemia in the context of T-ALL. The possibilities for prolactin as a novel tumor marker are explored. Disclosures:No relevant conflicts of interest to declare.

Delayed Diagnosis of Leukemia and Association With Morbid-Mortality in Children in Pernambuco, Brazil

The objectives of this study were to describe the interval between symptom onset and diagnosis of acute leukemia, to assess risk factors for delayed diagnosis, and its effect on early morbid-mortality and event-free survival (EFS). Records of children aged 1 month to 18 years diagnosed with acute leukemia were reviewed for clinical, demographic, and health care provider factors, and for time to diagnosis. Of 288 patients diagnosed, 55% had a delay in diagnosis. The median time to diagnosis was 31 days. There were significant associations between the diagnostic delay and the distance from the tertiary care hospital (P=0.04), initial consultation in an outpatient clinic (P=0.04), presenting symptoms of bone/joint pain (P=0.04), family with more than 3 children (P=0.02), birth order of third or greater (P=0.009), paternal age <30 years (P=0.03), and paternal education <8 years (P=0.008). There was no association between delayed diagnosis and early morbid-mortality or EFS at 5 years. Initial consultation in an outpatient setting, presenting symptoms of bone/joint pain, and birth order of third or greater remained statistically significant in multivariate analyses, but the delay did not have an impact on early morbid-mortality or EFS. Education of primary care providers in atypical presentations of acute leukemia may decrease the diagnostic delay.

Acute myelogenous leukemia presenting as atypical mastoiditis

Acute myelogenous leukemia presenting as atypical mastoiditis

Leukocytosis: a risk factor for myocardial infarction

Leukocytosis: a risk factor for myocardial infarction Suman K KotlaDepartment of Internal Medicine, Memorial Medical Center, Johnstown, PA, USAAbstract: Myocardial infarction commonly results from atherosclerotic lesions in the coronary arteries. Approximately 5% of patients with acute myocardial infarction do not have atherosclerotic disease. In this case report, we present an unusual leukostatic complication in a patient with acute myeloblastic leukemia and extreme hyperleukocytosis who presented with an acute myocardial infarction that resolved after leukopheresis. Myocardial infarction as the initial presentation of acute leukemia has been reported only rarely.Keywords: leukocytosis, myocardial infarction, leukostasis

Fatal intracranial hemorrhage as the initial presentation of acute lymphocytic leukemia: case report

Hemorrhagic complications of acute leukemia are well described and are a common cause of mortality in these patients. However, to our knowledge, fatal intracerebral hemorrhage (ICH) as an initial presentation of acute lymphocytic leukemia (ALL) has only been reported once. We report a case of previously undiagnosed ALL presenting with ICH. Our patient is a 17-year old male who was found unresponsive several hours after complaining of headache. Initial emergency room evaluation found the patient to have anisocoria with a fixed and dilated right pupil and demonstrated evidence of decorticate posturing. Imaging revealed a large right-sided intraparenchymal hemorrhage, intraventricular hemorrhage, midline shift, and uncal herniation. Laboratory evaluation showed marked leukocytosis with blastic predominance and evidence of disseminated intravascular coagulopathy. Emergent surgical intervention was performed. However, despite evacuation of the hematoma, the patient eventually progressed to clinical brain death. Usually, ICH is seen in ALL patients after the diagnosis has been made. We report a unique case of fatal intracranial hemorrhage as the initial presentation of ALL and discuss the possible management dilemmas to treat such entities. ALL should be kept in the broad differential diagnosis of spontaneous ICH, especially in a young patient with evidence of severe coagulopathy.

Acute myelomonocytic leukemia presenting with gingival enlargement as the only clinical manifestation

A 34 year old woman reported for evaluation of generalized gingival swelling pain and bleeding. The patient also reported menstrual irregularities. Based on the oral and systemic examinations and hematological investigations, a provisional diagnosis of ‘menstrual cycle associated gingivitis’ was made. The patient was referred for a gynecologic consultation. At the three-week dental recall, a worsening of gingival overgrowth with a necrotic component was noted. The hematologic investigations revealed markedly elevated leukocyte counts. The clinical and hematological findings led us to a diagnosis of leukemia. This report emphasizes the importance of the dentist as well as the physician (in this case, the gynecologist) in correlating the oral, systemic and hematological findings in the diagnosis and also of regular recall in the management of a case.

Acute myelogenous leukemia presenting as atypical mastoiditis

Abstract Acute leukemia presenting as otitis media is a rare presentation of the disease [1–5]. We present a patient that was diagnosed with acute myelogenous leukemia (AML) who had signs and symptoms of acute otitis media and mastoiditis. His workup revealed granulocytic sarcoma involving the superior sagittal sinus, sigmoid sinus, internal jugular vein, and parotid gland. This extensive involvement of granulocytic sarcoma has not been described. This case report highlights the importance of complete hematologic and radiologic workup prior to consideration for surgical intervention for mastoiditis.

急性骨髄性白血病 (FAB ; M5a) における精巣再発の1例

急性骨髄性白血病 (FAB ; M5a) における精巣再発の1例

Acute Myelogenous Leukemia Presenting as Atypical Mastoiditis

Acute Myelogenous Leukemia Presenting as Atypical Mastoiditis

Bilateral Extra Ocular Muscle Involvement with Proptosis as the Ophthalmic Manifestation and Primary Presentation of Acute Leukemia in an Adult

Bilateral Extra Ocular Muscle Involvement with Proptosis as the Ophthalmic Manifestation and Primary Presentation of Acute Leukemia in an Adult

Two cases of H1N1 influenza infection as the initial presentation of acute leukemia

Pandemic 2009 influenza A virus (H1N1) is a new influenza virus causing illness in human populations. Immunocompromised patients are at high risk for the acquisition of influenza and serious influenza-associated complications. However, there are no reports about patients with both newly diagnosed acute leukemia and H1N1 influenza infection. We reported 2 cases of previously healthy patients with H1N1 influenza infection as the initial presentation of acute leukemia.

Acute leukemia presenting with extramedullary diseases and completely normal hemogram: An extremely unusual manifestation unique to pre‐B ALL

Acute lymphoblastic leukemia (ALL) is a clonal hematological disease characterized by inadequate normal hematopoiesis secondary to excessive proliferation of leukemic blasts and their impaired differentiation. As a result, patients usually manifest symptoms related to bone marrow failure. It's very uncommon for ALL patients to present with normal hemogram. Herein, we describe two patients who presented with excruciating bone pain at orthopedic clinics. Osteopathy involving multiple bones was noted initially, but acute leukemia was never considered as one of the differential diagnoses because of the completely normal hemogram in both cases. Consequently, the diagnosis of leukemia was slightly delayed. Upon literature review, we found that ALL patients with solely extramedullary diseases and nearly normal hemogram had exclusively pre-B disease. We also propose a putative hypothesis for this interesting finding.

Acute leukemia presenting with blasts first found in the cerebrospinal fluid but not in the peripheral blood

Acute leukemia presenting with central nervous system (CNS) signs and symptoms is uncommon and prone to be misdiagnosed. Here, we report nine patients with acute leukemia, including five patients with acute lymphoblastic leukemia (ALL) and four patients with acute myeloid leukemia (AML). These patients presented with symptoms suggestive of involvement of multiple cranial nerves, the spinal cord, and meningeal involvement. Moreover, we found that all these patients unexpectedly showed the presence of blasts in the cerebrospinal fluid (CSF) but not in the peripheral blood despite repeated examinations. Bone marrow examination confirmed the presence of acute leukemia in these patients. Seven patients died within 18 months of diagnosis and two patients developed stable disease. Our findings show a novel presenting feature of acute leukemia and highlight the importance of CSF cytology in the diagnosis of acute leukemia.

Acute Lymphocytic Leukemia Presenting as an Isolated Scalp Nodule in an Infant

We describe the presentation and management of a patient referred for a presumed benign scalp lesion in infancy. The subcutaneous nodule was ultimately diagnosed as the first manifestation of acute lymphoblastic leukemia. We review leukemia cutis with special emphasis on the differential diagnosis of scalp nodules in infancy that may be encountered by the plastic surgeon.

Ischémie aiguë du membre inférieur révélant une leucémie aiguë. À propos d’un cas et revue de la littérature

Large vessel thrombosis is a very rare clinical presentation of acute leukemia which is usually revealed by hemorrhagic complications or thrombosis of small vessels. We present here the case of a patient with previously undiagnosed acute myeloid leukemia who was referred to our hospital with symptoms of acute ischemia of the left lower limb. Occlusion of the left popliteal artery due to a leucostasis was noted and successfully treated with emergency surgical thromboembolectomy and chemotherapy.

Spinal cord compression as the initial presentation of acute biphenotypic leukaemia

Acute biphenotypic leukaemia (BAL) is an uncommon haematological malignancy with features of myeloid and lymphoid origin and poor overall prognosis. We report a 68-year-old man who presented with rapidly progressive upper thoracic spinal cord compression secondary to an extradural lesion. A T2–3 decompressive laminectomy with tumour excision was performed. Histopathology confirmed the diagnosis of acute biphenotypic (B/myeloid) leukaemia. The patient had only minor post-operative improvement in pyramidal lower limb weakness. He succumbed to the disease three months post-diagnosis after failing induction chemotherapy. While central nervous system involvement with acute leukaemia is well recognised, this is the first reported patient with spinal cord compression secondary to this leukaemia subtype.

Arthritic presentation of acute leukemia in children: experience from a tertiary care centre in North India

The objectives of this study are to highlight the arthritic presentation of acute lymphoblastic leukemia (ALL) in children and to delineate features that could help differentiate it from juvenile idiopathic arthritis (JIA). We present a retrospective case control study based on records of the Pediatric Rheumatology Clinic, Advanced Pediatric Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India for the period January 2005-October 2008. We compared the clinical profile of 11 children referred to us with musculoskeletal complaints who were ultimately diagnosed to have ALL, with the clinical profile of an equal number of age and sex matched children with JIA. Important features that predicted a diagnosis of ALL and differentiated it from JIA were history of night pain (P = 0.001), non-articular bony pain (P = 0.001), presence of joint pain out of proportion to physical findings (P = 0.0001), anemia (P = 0.004), leucopenia (P = 0.045), lymphocytic predominance (P = 0.002) and thrombocytopenia (P = 0.012). In conclusion, children with musculoskeletal complaints are often referred to the rheumatologist for evaluation. The treating physician should always exclude the possibility of an underlying ALL especially if there are atypical clinical features or subtle hematological abnormalities.

巨核球系マーカー(CD41)を有したacute erythroblastic leukemiaの1例

巨核球系マーカー(CD41)を有したacute erythroblastic leukemiaの1例

Reliability of leukostasis grading score to identify patients with high‐risk hyperleukocytosis

Hyperleukocytosis, white blood cell (WBC) count exceeding 50 to 100 x 10 9 /L, mostly occurs in acute leukemias, is a clear adverse prognostic factor for overall survival, and is associated with increased early mortality. Novotny et al. [1] developed a score to grade the probability of leukostasis in patients with hyperleukocytic leukemia. It is based on the simple clinical evaluation of overall severity of symptoms, the presence of pulmonary or neurologic symptoms with assignment of a score. We retrospectively applied this leukostasis grading score (LGS) to patients admitted to our institution from 1995 to 2008 with a newly diagnosed acute leukemia presenting with hyperleukocytosis to identify patients at high risk of early death. Thirty-three patients presented hyperleukocytosis. Six patients died within 1 week. More than 75% of patients with hyperleukocytosis were assigned a LGS > 2 and almost 50% had an LGS of 3. Higher LGS was observed in patients with myeloid phenotype. LGS, age, bilirubin, creatinine, and lactate dehydrogenase (LDH) were the factors statistically associated with the occurrence of early death. Multivariate analysis confirms only LGS 3 as predictive of early death. The score is simple and is able to identify patients at higher risk of early death immediately requiring more aggressive treatment.

Pediatric leukemia revealed by a limping episode: A report of four cases

Acute limping in children is a common reason for consultation in pediatric emergency units. Acute leukemia is a rarely encountered disease in the orthopedic surgeon's activity. In addition, its clinical presentation is not typical and therefore is a source of possible diagnostic delay. For such reasons, there is a definite risk of undiagnosing the actual etiology of the limping episode. We report our experience with four cases of children initially seen in the pediatric emergency department for limping, as their revealing presentation of acute leukemia. The limb pain was highly variable. The radiographic work-up was always normal. Peripheral blood abnormalities were initially absent in one case and blastic cells were absent in two cases. The physician in charge should remember that paraclinical work-up normal results do not exclude a diagnosis of acute leukemia, that any drop in hematopoietic cell counts should call for a myelogram and that paraclinical exams, including the hemogram, should be repeated until a diagnosis and improvement or confirmed cure is achieved over time.