Severe aplastic anemia preceding acute lymphoblastic leukemia

Spontaneous Remission of Acute Lymphoblastic Leukemia Following Candida tropicalis Fungemia

Spontaneous remission (SR) in acute lymphoblastic leukemia (ALL) is a poorly understood phenomenon that has been sporadically reported in medical literature for over a century, and the molecular and immunologic mechanisms of remission pose interesting clinical questions. Furthermore, the often-transient nature of these remissions poses a challenge to physicians in formulating an approach to treatment. We report on a rare case of Candida tropicalis sepsis in a three-year-old female with high-risk ALL who received less than two months of treatment prior to sepsis and subsequent SR.

Scurvy: A treatable forgotten fatal differential diagnosis and potential etiology of leukemia and aplastic anemia in pediatric population

Scurvy is a rare nutritional deficiency disease which is less likely to be suspected and it mostly lead to delayed diagnosis. It can present with features which can mislead clinicians to misdiagnose the condition as leukemia or aplastic anemia. This can subject patients to the wrong management which leads to poor outcome and increased preventable morbidity and mortality. Vitamin C deficiency is still prevalent among pediatric population even in the modern days and should no longer be considered as historical condition. Chromosomal fragility has been greatly accounted for the development of leukemia and aplastic anemia secondary to various triggers. The role of vitamin C toward DNA stability, prevention, and control of mutations have been documented. Vitamin C plays a vital role in hematopoiesis by controlling regulation and prevent dysfunction of hematopoietic stem cells. Scurvy deficiency has been a silent growing clinical problem which needs a high index of suspicion for a clinician to pick it. It should be considered as one among potential differential diagnosis of leukemia and aplastic anemia especially in the pediatric population. History of any dietary restriction should be obtained and addressed properly. Serum vitamin C should be among the essential laboratory workout in diagnosis of both leukemia and aplastic anemia. All patients suspected to have such conditions should be screened and supplemented for vitamin C deficiency irrespective of positive confirmatory test results of leukemia or aplastic anemia since the probability of co-occurrence is likely also. Moreover, studies should be conducted to explore the clinical link, if any, between vitamin C deficiency or insufficiency and development of leukemia and aplastic anemia among the pediatric population given its physiological and genomic role in hematopoiesis. Furthermore, the potential pharmacological therapeutic use of vitamin C in treatment of leukemia and aplastic anemia should be determined clinically.

Slowly progressing acute lymphoblastic leukemia with prolonged leukopenia

Acute lymphoblastic leukemia is typically characterized by leukocytosis, resulting from the uncontrolled proliferation of malignant cells. However, we report an atypical case of acute lymphoblastic leukemia that presented with leukopenia and exhibited a protracted clinical course spanning 6 months. The patient, a 45-year-old female, initially presented to our hospital with recurrent fever and was found to have lymphoblasts in a hypoplastic bone marrow. Upon further investigation, the patient was diagnosed with B-cell lymphoblastic leukemia, not otherwise specified, based on cell surface antigen expression and genetic abnormalities. Notably, the patient demonstrated persistently low white blood cell and neutrophil counts, without evidence of increasing lymphoblast infiltration in the bone marrow during the ensuing 6-month period. Subsequent chemotherapy led to normalization of hematopoiesis and disappearance of lymphoblasts, resulting in complete remission of the disease.

Transient bone marrow hypoplasia preceding T-Cell acute lymphoblastic leukemia: a case report

Background

Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy and is characterised by hyperproliferation of malignant lymphocytes in the bone marrow. Rarely, ALL may be preceded by a period of pancytopenia and bone marrow hypoplasia which spontaneously recovers. This phenomenon, which has not before been described in T-cell ALL, is referred to as transient bone marrow hypoplasia.

Case presentation

A 5-year-old boy who presented with high-grade fever and generalised lymphadenopathy, was found to have pancytopenia on peripheral blood count and bone marrow hypoplasia. He was observed over a one-month period during which his bone marrow and peripheral blood counts recovered spontaneously. Symptoms recurred after 4 months and he was found to have blast infiltration of the bone marrow and diagnosed with T-cell ALL.

Conclusion

Cases of transient bone marrow hypoplasia or overt aplastic anemia with spontaneous recovery and then followed by B-cell ALL or Acute Myeloid Leukemia have been described previously in the medical literature. This is the first case of transient bone marrow hypoplasia resulting into ALL of T-cell immunophenotype. While marrow hypoplasia preceding ALL remains poorly understood, it suggests an antecedent environmental insult to lymphoid progenitors or a germline abnormality that predisposes to lymphoid dysplasia. This may provide clues to the hitherto unknown pathophysiological process and etiological factors that precede the majority of childhood ALL cases. This case enlightens pediatricians about the existence of such rare cases so as to periodically follow up children with pancytopenia and/or bone marrow hypoplasia for prolonged periods even after apparent recovery.

The distinguishable DNA whole genome methylation profile of 2 cases of pediatric precursor B acute lymphoblastic leukaemia (BCP ALL) with prodromal, preleukemic phase: A case report

RATIONALE

A prolonged, prodromal phase before definitive paediatric precursor B acute lymphoblastic leukaemia (BCP ALL) diagnosis is rarely observed.

PATIENTS CONCERNS

In the first, the patient presented with an aplastic preleukemic phase, whilst the second presented with a rheumatic-like preliminary phase.

DIAGNOSES

The case reports of two patients with BCP ALL with a prodromal phase lasting a few weeks are presented.

INTERVENTIONS AND OUTCOMES

DNA whole genome profile methylation analysis of bone marrow cells obtained at diagnosis revealed a pattern of methylation that was readily distinguishable from both healthy and standard course BCP ALL bone marrow samples.

LESSONS

The biological implication of this observation remains unclear, with many differentially methylated loci involved in many processes like neurogenesis, cell projection organization and adhesion along with leucocyte activation and apoptosis. The prevalence and clinical significance of these methylation changes is unknown but this data indicates that the epigenetic basis of BCP ALL with a prolonged, prodromal phase requires a more detailed assessment.

Spontaneous remission of acute lymphoblastic leukemia: A case report

Spontaneous remission (SR) in acute lymphoblastic leukemia (ALL) is a rare phenomenon, but the disease course and its underlying processes are of basic and clinical interest. Herein is reported the case of a pregnant, 31-year-old patient who developed ALL, followed by septic shock and SR of ALL. Information is summarized from earlier case reports and incidences of SR in ALL, to identify common patterns. Furthermore, the phenomenon of SR is compared with another disease variant of ALL, termed prodromal or preceding-ALL (pre-ALL). SR and the aleukemic phase in pre-ALL are associated with fever and/or sepsis and have similar kinetics and epidemiology. Therefore, pre-ALL not only closely resembles SR in ALL, but both conditions may represent a single disease entity. Production of pro-inflammatory cytokines and immune cell effects may induce temporary remission of ALL and the suppression of hematopoiesis. In contrast to SR in other types of cancer, all documented cases of SR in ALL were only transient. However, the disease can still be effectively treated with standard ALL therapies following relapse.

Hypocellular acute myeloid leukemia treated with bone marrow transplantation

Hypocellular acute myeloid leukemia (AML) mainly occurs in elderly patients, and is extremely rare in childhood. There is still no established treatment for hypocellular AML. We report the case of an 11-year-old boy with hypocellular AML who was treated successfully with allogenic bone marrow transplantation (allo-BMT). He presented with fever, pallor and pancytopenia. Bone marrow aspiration and biopsy confirmed a diagnosis of hypocellular AML. Although low-dose cytarabine induced reduction of blasts, it did not lead to complete remission. He subsequently received myeloablative conditioning and allo-BMT. Graft-versus-host disease (GVHD) prophylaxis included short-course methotrexate and cyclosporine. Neutrophil engraftment (>5 × 10⁸ /L) and platelet recovery (>10 × 10¹⁰ /L) were achieved on days 13 and 27, respectively. He developed acute GVHD of the skin (grade 2), which responded well to treatment with prednisolone. He has remained in complete remission for 5 years since allo-BMT. We consider allo-BMT to be feasible for children with hypocellular AML.

Serum amyloid A1 and plasminogen as predictory proteins to monitor the progression of preleukemic diseases towards acute lymphoblastic leukaemia

SAA1 and plasminogen as additional predictory molecules to monitor the progression of preleukemic diseases towards ALL.

Transient pancytopenia preceding adult acute lymphoblastic leukemia with chromosomal abnormalities including the Philadelphia chromosome: A case report and review of the literature

A preleukaemic phase, typified by transient pancytopenia, is a rare occurrence that usually affects children and adolescents. The present study reports the case of a 50-year-old woman with transient pancytopenia, which manifested as a fever, cough and severe anemia. Three weeks following treatment of pancytopenia with antibiotics, red blood cell and platelet transfusion, granulocyte colony-stimulating factor and human γ globulin, the condition of the patient was improved. However, 3 weeks following discharge from hospital, the patient was diagnosed with acute lymphoblastic leukemia (ALL) with complex chromosomal abnormalities, including Philadelphia chromosome and P190 breakpoint cluster region-ABL. Complete remission was achieved following one course of combination chemotherapy. In conclusion, adult ALL with pancytopenia as a preceding symptom is rare, difficult to diagnose early and easily misdiagnosed. In addition, the pathogenesis of ALL and the precipitating factors underlying this disease require further investigation.

Pancytopenia - (?) An obstacle in the diagnosis and outcome of pediatric acute lymphoblastic leukemia

Context:

Acute lymphoblastic leukemia (ALL) ranks first among pediatric malignancies. 8–12% of ALL present with pancytopenia and 2% with hypocellular marrow a. Diagnosis of ALL in the background of pancytopenia and aplastic bone marrow is difficult.

Aims:

This study was aimed to compare the clinicopathologic, genetic, and outcome of paediatric ALL patients with and without pancytopenia.

Settings and Design:

This is a retrospective cross-sectional study.

Subjects and Methods:

The study included all ALL patients presenting with pancytopenia. The control group included equal number of randomly selected patients with ALL without pancytopenia treated during the same period. Ethics committee approved this study. The demographic, laboratory, and treatment-related details were retrieved from the records and entered in an Excel sheet.

Statistical Analysis Used:

Data was analyzed with Chi-square test with IBM SPSS statistics 16 software.

Results:

Diagnosis by peripheral smear is significantly lower (P = 0.015) in comparison with the control group. There is no significant difference in diagnosis between the groups by bone marrow aspirate (P = 0.731) and biopsy (P = 0.849). The diagnosis of leukemia is misdiagnosed as hypo cellular/aplastic marrow in 10% of the pancytopenic patients. Flow cytometry yielded the diagnosis in all the pancytopenic patients. Though cytogenetic abnormalities are more common in pancytopenic group, it is not statistically significant (P = 0.106). There is no significant difference in treatment outcome between the groups (P = 0.0827%).

Conclusions:

Clinical expertise is highly essential to evaluate a case of pancytopenia to diagnose leukemia. Pancytopenia is an obstacle in the diagnosis of ALL without immunophenotyping. There is no significant difference in the outcome between the two groups.

Acute lymphoblastic leukemia of childhood presenting as aplastic anemia: report of two cases

Acute lymphoblastic leukemia is the most common malignancy in pediatric patients; its diagnosis is usually easy to establish as malignant lymphoblasts invade the bone marrow and peripheral blood. Some acute lymphoblastic leukemia patients may initially present with pancytopenia and a hypoplastic bone marrow leading to the initial diagnosis of aplastic anemia. In most of these patients clinical improvement occurs, with normalization of the complete blood count within six months, although recovery can also develop a few weeks after initiating steroid therapy. The etiologic relationship between the aplastic anemia features and the subsequent overt development of acute lymphoblastic leukemia has not been established. We describe the cases of two children who presented with severe infection and signs and symptoms of aplastic anemia confirmed by bone marrow aspirate and bone marrow biopsy that developed acute lymphoblastic leukemia thereafter. No specific therapy for aplastic anemia was administered, nevertheless a full spontaneous recovery was observed in both cases. Acute lymphoblastic leukemia was successfully treated with standard chemotherapy, both children remaining in complete remission 16 and 17 months after their initial aplastic anemia diagnosis.

Pediatric Bone Marrow Interpretation

The evaluation of pediatric bone marrow poses specific challenges when compared with the general adult population. These challenges stem in part from the higher likelihood of congenital disorders with hematopoietic manifestations, some of which may give rise to hematologic malignancies. Familiarity with the spectrum of disorders seen in the pediatric age group allows for an appropriate and focused differential diagnosis. This review addresses the diagnostic workup of pediatric bone marrow samples, as directed by the peripheral blood and bone marrow findings in the context of the patient's clinical history. Recommendations for the appropriate use of ancillary studies in various scenarios are provided.

Hypocellular acute myeloid leukemia with bone marrow necrosis in young patients: two case reports

INTRODUCTION

Hypocellular variants of acute myeloid leukemia are very rare and almost always occur in old aged patients. In contrast, hypocellular acute lymphoblastic leukemia usually occurs in children.

CASE PRESENTATION

We report two Indian patients with hypocellular acute myeloid leukemia, a 32-year-old woman and a 13-year-old boy. Interestingly, one of the patients also showed bone marrow necrosis.

CONCLUSION

Hypocellular acute myeloid leukemia is a rare entity and can affect young individuals. It can be considered as a rare cause of bone marrow necrosis.

Diagnostic pitfalls in acute leukemia

In most children presenting with the common signs and symptoms of leukemia, the diagnosis is readily made. However, unusual features of the disease and the absence of abnormalities on the complete blood count may render the diagnosis problematic, especially if this malignancy is not suspected. The current report focuses on the unusual presentation of leukemia and the difficulties in the diagnosis of the malignancy.

Adult hypocellular acute leukaemia with lymphoid differentiation

The rare hypocellular variants of acute leukemia (AL) previously also termed smouldering leukemia, almost always exhibit myeloid differentiation. Very rare cases of hypocellular AL with lymphoid differentiation have been reported, usually in children. This paper describes two cases (an 87-year-old woman and a 79-year-old man) in whom the blood findings were suggestive of AL. Paraffin-embedded bone marrow biopsy specimens revealed similar findings in both patients: there was severe hypocellularity, the cells of normal hemopoiesis were greatly reduced in number, and there was a diffuse increase in blast cells, which represented more than 50% of nucleated marrow cells. The blasts coexpressed TdT and CD34 and were negative for myeloperoxidase, CD117, CD68 and naphthol AS-D chloroacetate esterase. For the first time immunohistochemical Pax-5/CD34 doublestainings are provided, which revealed the blasts in one case to coexpress Pax-5 and CD34. All the blasts were CD79a-positive and 20% were also CD10-positive. In the other case, 20% of the blasts were CD79a-positive, 30% coexpressed Pax-5 and CD34 by doublestaining, and showed a clonal rearrangement of the immunoglobulin heavy chain gene. Thus a diagnosis of AL of lymphoid lineage, hypocellular variant, was made on the basis of immunohistochemical findings. The clinical course appears to be similar to that of hypocellular AML, as neither patient has developed overt leukemia during the one-year follow-up period.

Three cases of typical aplastic anaemia associated with a Philadelphia chromosome

We report three cases of typical aplastic anaemia (AA) associated with a Philadelphia chromosome. This translocation was detected at the time of diagnosis of AA (one patient) and when overt leukaemia was diagnosed (two patients: one chronic myeloid leukaemia and one acute lymphoblastic leukaemia) after AA therapy and recovery of blood counts. We discuss the literature arguments about considering some cases of AA as preleukaemic disorders and suggest that our cases illustrate the association of AA with a clonal malignant disorder. We conclude that cytogenetic analysis is necessary at diagnosis of AA or after recovery of blood counts.

Bone marrow aplasia with prominent atypical plasmacytic proliferation preceding acute lymphoblastic leukemia

A two-year-old boy presented with pancytopenia. Bone marrow examination revealed an aplastic marrow with prominent immature plasma cell proliferation, which mimicked plasma cell leukemia. Immunohistochemistry, however, revealed a polyclonal population consistent with a reactive process, excluding plasma cell neoplasia. Administration of granulocyte-colony stimulating factor resulted in recovery of normal hematopoiesis with resolution of plasmacytosis. Seven months later, the patient had an elevated white blood cell count and bone marrow findings diagnostic of acute lymphoblastic leukemia. To the best of our knowledge this is the first reported case of bone marrow aplasia with prominent polyclonal plasmacytosis presenting as a prodrome of acute lymphoblastic leukemia in childhood.

Pancytopenic prodrome (pre-ALL) of acute lymphoblastic leukemia in adults: possible pathogenesis

We report two cases of adult acute lymphoblastic leukemia presenting with preleukemic phase of pancytopenia with a few abnormal lymphoid cells in bone marrow aspirates. The initial diagnosis of each case was suspicious aplastic anemia and hypoplastic anemia. Both cases progressed to overt acute lymphoblastic leukemia within 1 year. We suggest that initial pancytopenic phase (pre-ALL) may precede the diagnosis of acute lymphoblastic leukemia in adults and differential diagnosis from myelodysplastic syndrome and primary aplastic anemia will be needed. We also suggest that primary bone marrow lymphoma and "primary unknown metastatic lymphoma of bone marrow" may be possible as the pathogenesis in a case like ours.

Practical aspects in the diagnosis and management of aplastic anemia

Aplastic anemia may result from several pathogenic mechanisms, the most common is idiopathic. The current definitive treatments for aplastic anemia are bone marrow transplantation (BMT) or immunosuppressive (IS) therapy. The benefits of each are comparable. However, certain subsets of patients derive superior benefit from one or the other. Bone marrow transplantation is the initial treatment of choice for young patients (< 20 years old). It results in the complete reconstitution of hematopoiesis, whereas autologous hematopoietic remissions after IS therapy are more susceptible to relapse. Survival rates after BMT, in patients between the ages of 20 and 40, are comparable to those reported for IS therapy. Better survival rates after BMT have been achieved with improved conditioning regimens and graft-versus-host disease prophylaxis. For patients older than 40, the treatment of choice is IS. Long-term complications of IS therapy include recurrence and development of clonal myeloid disorders. Long-term complications after BMT include graft-versus-host disease and secondary neoplasms. The IS regimen includes the combination of antithymocyte globulin and cyclosporin A. The addition of growth factor to the IS regimen seems promising; however, their use on their own is not recommended. Androgens have been shown to be inferior in the treatment of aplastic anemia. The role of BMT from an unrelated donor is being investigated.

Development of minimally differentiated acute myeloblastic leukemia with novel isochromosome 18p and antecedent aplastic anemia

We describe a case of acute myeloblastic leukemia with a novel isochromosome 18, i(18)(p10), preceded by aplastic anemia for six months. The patient is a cotton grower chronically exposed to pesticides. The significance of this chromosomal abnormality is unknown. The possible relationship to the preceding history of aplastic anemia and occupational pesticide exposure is speculated on. The possible mechanism of the association of acute leukemia and aplastic anemia is discussed.

Severe aplastic anaemia in the Nordic countries: a population based study of incidence, presentation, course, and outcome

PURPOSE

Incidence data for severe aplastic anaemia (SAA) in children are scanty and vary. Few population based studies have been reported. A retrospective and prospective study was conducted to determine the incidence and course of SAA.

PATIENTS AND METHODS

All children with a diagnosis of SAA in the Nordic countries from 1982 through 1993 were registered and have been followed up since 1987.

RESULTS

A total of 101 children were diagnosed with SAA. The mean annual child population was 4.31 million. A constant incidence of 1.95/million children/year was found: 2.4 for boys and 1.5 for girls. A non-significant increase of cases occurred from November to March. Possible aetiological agents were noted in 29%. The actuarial survival was 79% after one year and 68% after five years without significant difference between boys and girls.

CONCLUSION

The incidence of SAA in the Nordic countries remains stable with a preponderance among boys. SAA has still a high initial mortality and a risk of late deaths.