Acute promyelocytic leukemic involvement of the optic nerves following mitoxantrone treatment for multiple sclerosis

Case Report: Extramedullary Acute Promyelocytic Leukemia: An Unusual Case and Mini-Review of the Literature

Background

Acute promyelocytic leukemia (APL) constitutes a serious hematological emergency necessitating rapid diagnosis and therapy to prevent lethal bleedings resulting from APL-induced thrombocytopenia and coagulopathy. Atypical manifestations of APL, such as extramedullary disease at first presentation, pose diagnostic challenges and delay the onset of appropriate therapy. Nevertheless, extramedullary manifestations of APL are mostly accompanied by blood count alterations pointing to an underlying hematological disease. In this report, we present the first case of APL bearing close resemblance to a metastasized laryngeal carcinoma with normal blood counts and absent coagulopathy.

Case Presentation

A 67-year-old man with a previous history of smoking was admitted to our hospital with progressive hoarseness of voice, odynophagia, dysphagia and exertional dyspnea. Laryngoscopy revealed a fixed right hemi larynx with an immobile right vocal fold. Imaging of the neck via magnetic-resonance imaging (MRI) and positron emission tomography–computed tomography (PET/CT) with F-18-fluordeoxyglucose (FDG) showed a large hypermetabolic tumor in the right piriform sinus and tracer uptake in adjacent lymph nodes, highly suspicious of metastasized laryngeal carcinoma. Surprisingly the histological examination revealed an extramedullary manifestation of acute promyelocytic leukemia. Remarkably, blood counts and coagulation parameters were normal. Moreover, no clinical signs of hemorrhage were found. PML-RARA fusion was detected in both laryngeal mass and bone marrow. After diagnosis of APL, ATRA-based chemotherapy was initiated resulting in complete remission of all APL manifestations.

Conclusions

This is the first case report of APL initially presenting as laryngeal chloroma. Additionally, we performed a comprehensive literature review of previously published extramedullary APL manifestations. In aggregate, a normal blood count at first presentation constitutes an extremely rare finding in patients initially presenting with extramedullary APL manifestations.

Radiological Features of Bilateral Sequential Leukaemic Optic Nerve Infiltration: A Case Report

Leukaemic infiltration of the optic nerve is an oncologic emergency that can lead to a significant risk of irreversible vision loss and has an overall poor systemic prognosis. We present the case of a 77-year-old man in previous systemic remission from acute myeloid leukaemia (AML) who developed bilateral sequential leukaemic optic nerve involvement with eventual complete vision loss. A review of the clinical and radiological characteristics of optic nerve infiltration in AML is provided. Profound vision loss to the order of 20/200 or worse is common. Magnetic resonance imaging features include optic nerve thickening, enhancement of the nerve sheath, T2 hyperintensity and restricted diffusion. Urgent orbital radiotherapy is indicated prior to the onset of irreversible optic nerve damage.

The Ocular Manifestations of Drugs Used to Treat Multiple Sclerosis

Recent times have seen an increase in the number of options to treat multiple sclerosis. Ocular manifestations of multiple sclerosis are well known to treating physicians; however, the medications used to treat multiple sclerosis can also have ocular side effects. This review article focuses on the ocular manifestations of corticosteroids and disease-modifying agents such as interferon, fingolomod, natalizumab, alemtuzumab and mitoxantron used to treat the disease. The ocular manifestations of multiple sclerosis treatments can be varied depending on the drug used, and include retinopathy, chronic central serous chorioretinopathy, macular oedema, Graves' ophthalmopathy and cortical blindness. These effects may be specific to the drug or secondary to their immunosuppressive effect. The association of macular oedema with fingolomod is clear and merits ocular screening for toxicity. The immunosuppressive nature of the treatments makes patients prone to acquired infections. Hence, if a patient with multiple sclerosis presents with vision loss, infectious and drug-induced aetiology should be considered alongside relapses of multiple sclerosis itself as a cause.

Gene-Set Local Hierarchical Clustering (GSLHC)--A Gene Set-Based Approach for Characterizing Bioactive Compounds in Terms of Biological Functional Groups

Gene-set-based analysis (GSA), which uses the relative importance of functional gene-sets, or molecular signatures, as units for analysis of genome-wide gene expression data, has exhibited major advantages with respect to greater accuracy, robustness, and biological relevance, over individual gene analysis (IGA), which uses log-ratios of individual genes for analysis. Yet IGA remains the dominant mode of analysis of gene expression data. The Connectivity Map (CMap), an extensive database on genomic profiles of effects of drugs and small molecules and widely used for studies related to repurposed drug discovery, has been mostly employed in IGA mode. Here, we constructed a GSA-based version of CMap, Gene-Set Connectivity Map (GSCMap), in which all the genomic profiles in CMap are converted, using gene-sets from the Molecular Signatures Database, to functional profiles. We showed that GSCMap essentially eliminated cell-type dependence, a weakness of CMap in IGA mode, and yielded significantly better performance on sample clustering and drug-target association. As a first application of GSCMap we constructed the platform Gene-Set Local Hierarchical Clustering (GSLHC) for discovering insights on coordinated actions of biological functions and facilitating classification of heterogeneous subtypes on drug-driven responses. GSLHC was shown to tightly clustered drugs of known similar properties. We used GSLHC to identify the therapeutic properties and putative targets of 18 compounds of previously unknown characteristics listed in CMap, eight of which suggest anti-cancer activities. The GSLHC website http://cloudr.ncu.edu.tw/gslhc/ contains 1,857 local hierarchical clusters accessible by querying 555 of the 1,309 drugs and small molecules listed in CMap. We expect GSCMap and GSLHC to be widely useful in providing new insights in the biological effect of bioactive compounds, in drug repurposing, and in function-based classification of complex diseases.

Granulocytic sarcoma of colon in a patient with acute promyelocytic leukemia

Granulocytic sarcoma in a patient with acute promyelocytic leukemia (APML) has been described often in the relapse setting, however primary presentation of APML as granulocytic sarcoma is rare. We present a case of a 29 year old male who was evaluated for thrombocytopenia with haematochezia and a diagnosis of acute promyelocytic leukemia was established after the colonic biopsy was reported as a granulocytic sarcoma.

Multiple sclerosis. Part 2: ophthalmic issues in MS therapy

PURPOSE OF REVIEW

This update includes topics relating to the treatment of multiple sclerosis (MS) for the ophthalmologist.

RECENT FINDINGS

Despite investigation into numerous genetic and environmental factors, the cause of MS remains elusive. MS is a disease of the central nervous system that mainly affects young people and usually progresses over time, leading to disability in multiple areas, including mobility, cognition, affect and vision. It is likely that, as novel MS treatments are introduced, there will be a greater interest in tracking visual function and monitoring for visual complications.

SUMMARY

Current therapies in MS include interferon, glatiramer, natalizumab and mitoxantrone. Other MS treatments are imminent, and include oral medications, monoclonal antibodies and chemotherapy. Treatment of the visual symptoms in MS and the side effects of MS therapies are reviewed in this article.