Chorea, eosinophilia, and lupus anticoagulant associated with acute lymphoblastic leukemia

Dancing with disorder: chorea - an unusual and neglected manifestation of antiphospholipid syndrome

OBJECTIVES

Chorea, characterised by involuntary, irregular movements, is a rare neurological manifestation of antiphospholipid syndrome (APS). The specific clinical features remain unclear. This study aimed to summarise the available evidence on antiphospholipid antibody (aPL)-associated chorea.

METHODS

We used a mixed-methods approach, combining data from patients with chorea with aPL positivity admitted to Peking Union Medical College Hospital (PUMCH) from 2014 to 2024, with cases identified in public databases since 1983. We collected and analysed clinical, laboratory, and imaging results, along with their treatments and outcomes.

RESULTS

A total of 180 patients with incident aPL-associated chorea were included (13 from PUMCH and 167 from the literature). The majority (81.7%) were female, with a mean age of chorea onset 22.8 years (SD=16.0). Chorea was the initial symptom in 87.9% of cases and often occurred as a single episode (67%), involving bilateral limbs (58.8%) and both upper and lower limbs (87.2%). 43.3% met the 2023 American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) APS classification criteria. Thrombocytopenia (30.0%) and arterial thrombosis (29.1%) were the most common manifestations. Lupus anticoagulant was positive in 84.2% of patients, anticardiolipin IgG in 70.8%, and anti-β2 glycoprotein I IgG in 52.9%. Among those who had results available for the three tests, 57.6% were triple-positive. ANAs were positive in 63.6%. MRI revealed basal ganglia lesions in only 14.8% of patients, whereas all positron emission tomography (PET) scans showed contralateral striatal hypermetabolism. Treatment varied, with most receiving combination therapies of neuroleptics, anticoagulants, antiplatelets, steroids and immunosuppressants. Chorea completely or partially improved in 95.5% of patients.

CONCLUSION

Chorea is a significant but under-recognised manifestation of APS, predominantly affecting young women and often presenting as the initial symptom. Characteristic PET findings of contralateral striatal hypermetabolism can assist in diagnosis. Treatments with glucocorticoids and immunosuppressive therapies appear beneficial. Further research is needed to understand the pathophysiology and optimise management strategies for aPL-associated chorea.

Hypereosinophilia in Acute Lymphoblastic Leukemia: Two Cases with Review of Literature

Eosinophilia is rare in acute leukemia at presentation. Discrete reports and case studies in recent years have created significant interest in the field of "Acute leukemia with eosinophilia". We herein present two cases of eosinophilia in association with acute lymphoblastic leukemia with brief review of literature in this field. First case is about 21-year-old female who presented with mediastinal mass along with leukocytosis and hypereosinophilia. On evaluation, she was found to have T cell acute lymphoblastic leukemia. After ruling out benign causes of eosinophilia, she was treated with modified BFM-90 protocol. Her eosinophilia resolved after 4 weeks of induction therapy. Second case is about 32-year-old male who was diagnosed as a case of mixed phenotype leukemia (B cell/myeloid type) along with severe eosinophilia. His hypereosinophilia finally resolved by week 16 of modified BFM-90 protocol. Diagnosing ALL is challenging when eosinophilia is the initial presentation. These two cases emphasize on the importance of considering ALL amongst one of the etiological causes of eosinophilia as delay in diagnosis endangers patient's life at risk. Also eosinophilia per se is an independent poor risk factor, hence prompt diagnosis and early treatment is the key in all such cases.

Autoimmune chorea in adults

OBJECTIVES

To determine the characteristics of adult-onset autoimmune chorea, and compare paraneoplastic and idiopathic subgroups.

METHODS

Thirty-six adults with autoimmune chorea were identified at Mayo Clinic (Rochester, MN) from 1997 to 2012. Medical record and laboratory data were recorded. Nonparaneoplastic (n = 22) and paraneoplastic cases (n = 14) were compared.

RESULTS

Women accounted for 21 patients (58%). Median age at symptom onset was 67 years (range 18-87 years). We estimated the incidence for Olmsted County was 1.5 per million person-years. Symptom onset was subacute in all. Chorea was focal (20 patients) or generalized (16 patients). Although chorea predominated, other neurologic disorders frequently coexisted (29 patients); abnormal eye movements were uncommon (4 patients). No patient had NMDA receptor antibody or any immunoglobulin (Ig)G yielding a detectable immunofluorescence binding pattern restricted to basal ganglia. Two had synaptic IgG antibodies novel to the context of chorea (GAD65, 1; CASPR2, 1). In the paraneoplastic group, 14 patients had evidence of cancer. Of 13 with a histopathologically confirmed neoplasm, small-cell carcinoma and adenocarcinoma were most common; 6 patients had a cancer-predictive paraneoplastic autoantibody, with CRMP-5-IgG and ANNA-1 being most common. In the idiopathic group, 19 of the 22 patients had a coexisting autoimmune disorder (most frequently systemic lupus erythematosus and antiphospholipid syndrome); autoantibodies were detected in 21 patients, most frequently lupus and phospholipid specificities (19 patients). The paraneoplastic group was older (p = 0.001), more frequently male (p = 0.006), had more frequent weight loss (p = 0.02), and frequently had peripheral neuropathy (p = 0.008).

CONCLUSIONS

Autoimmune chorea is a rare disorder with rapid onset. Male sex, older age, severe chorea, coexisting peripheral neuropathy, and weight loss increase the likelihood of cancer.

Antiphospholipid antibodies associated with malignancies: clinical and pathological characteristics of 120 patients

OBJECTIVE

To describe the different types of malignancies associated with antiphospholipid antibodies (aPL).

METHODS

We performed a computer-assisted (MEDLINE, National Library of Medicine, Bethesda, MD) search of the literature from 1966 to 2003 to identify all cases of malignancies having aPL.

RESULTS

One hundred twenty patients were found. The mean age was 56+/-17 years (range 5 to 88). Sixty-two (52%) patients were men and 58 (48%) were women. A heterogeneous group of malignancies were found. Regarding hematological malignancies, 10 (8%) patients suffered from B-cell lymphoma, 8 (7%) from spleen lymphoma, 7 (6%) from chronic myeloid leukemia, and 6 (5%) from non-Hodgkin's lymphoma (NHL). Regarding solid tumors, renal cell carcinoma was diagnosed in 7 (6%) patients, primary tumor with unknown origin in 7 (6%), lung adenocarcinoma in 6 (5%), breast carcinoma in 6 (5%), and melanoma in 6 (5%). The main aPL-related manifestations were thrombocytopenia (25%), cerebrovascular accidents (24%), deep vein thrombosis (19%), pulmonary embolism (15%), and heart valve lesions (9%). In 17 cases, catastrophic antiphospholipid syndrome was considered to be triggered by the malignancy. Seventy-one (63%) of 113 patients recovered or are still alive after cancer treatment. Twenty-three (35%) of 65 patients achieved aPL remission after proper treatment of the malignancy.

CONCLUSIONS

It is important to bear in mind, especially in elderly patients, that thrombotic events associated with aPL can be the first manifestation of malignancy. At the same time, the presence of aPL in patients with malignancies has important implications in their treatment and prognosis.

Acute lymphoblastic leukemia presenting with urticarial plaques and hypereosinophilia in a child

Our report describes a previously healthy 10-year-old female who was seen for urticarial plaques and mild loss of appetite. An initial laboratory workup revealed an elevated leukocyte count of 30,000/microL and a peripheral eosinophil count of 22,500/microL. A skin biopsy showed a marked hypersensitivity tissue response with abundant eosinophils. Further investigation of her peripheral eosinophilia uncovered Giardia lamblia in a stool sample. Despite treatment with the anti-parasitic agent furazolidone, the patient's urticarial plaques, leukocyte count, and peripheral eosinophil count remained unchanged. A bone marrow biopsy confirmed a diagnosis of acute lymphoblastic leukemia (ALL). ALL with hypereosinophilia (ALL/Eo) represents a rare and distinct subset of ALL, with more than 30 cases documented in the literature. Our discussion summarizes the clinical aspects of this disease and reviews the reported dermatological manifestations of ALL/Eo.

Childhood acute myelomonocytic leukemia (AML-M4) presenting as catastrophic antiphospholipid antibody syndrome

: The authors describe a 15-year-old girl presenting with a cerebral ischemic stroke as the first manifestation of catastrophic antiphospholipid antibody syndrome secondary to acute myeloid leukemia (AML). Despite treatment with anticoagulants, therapeutic plasma exchange, and chemotherapy, the patient developed multiorgan thromboses and failure, eventually culminating in death. This unusual presentation of AML has not been previously described in children. Clinical features of antiphospholipid antibody syndrome and current knowledge regarding its association with malignancies are reviewed.

Acute lymphoblastic leukemia with hypereosinophilia: report of a case with 5q deletion and review of the literature

Peripheral blood eosinophilia as a presentation of acute lymphoblastic leukemia (ALL) has only rarely been reported. The eosinophilia is thought to be a nonneoplastic reaction to the neoplastic lymphoblasts. We present the case of a 5-year-old girl who developed peripheral hypereosinophilia with no circulating blasts prior to her diagnosis of B-cell lineage ALL. Cytogenetic study showed a hyperdiploid blast population with 5q deletion. Persistent peripheral hypereosinophilia should always be fully investigated, the possibility of a malignancy including ALL needs to be excluded, even in the absence of peripheral cytopenias and circulating blasts.

Case report: thoracic aorta thrombus with systemic embolization: a rare paraneoplastic antiphospholipid syndrome?

Antiphospholipid syndrome (APS) is characterized by venous and/or arterial thromboses in the presence of the lupus anticoagulant, anticardiolipin antibodies, or both. Antiphospholipid syndrome may occur as a primary disease or in patients with systemic lupus erythematosus or other autoimmune, infectious, or neoplastic disorders. This is a case of APS associated with chronic myelomonocytic leukemia and complicated by a large descending thoracic aorta thrombus responsible for lower limb and visceral emboli. The intraaortic clot was discovered by transesophageal echography (TEE). The association of APS with chronic leukemias has only rarely been described and, as far as can be ascertained, the location of a thrombus in the descending thoracic aorta has never been reported for this syndrome. This case illustrates the crucial role of TEE in the assessment of patients with systemic embolizations.