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Wednesday, 30 December 2020

AN UNUSUAL DEBUT OF ACUTE LEUKEMIA

Written by Eva Barbón Alonso | Beatriz Villanueva Iribarren | María Ordóñez Marina, Posted in Volumen15

Figure 1. May-Grünwald-Giemsa staining picture taken with Cellavision® of peripheral blood frame of the patient, showing blasts with a high nuclear-to-cytoplasmic ratio and some nucleoli.

It is presented the case of an 89-year-old woman with sudden and non-transient onset of strength loss, disorientation and speech difficulties. The patient was presented to the nearest referral hospital, where initial examination showed dysphagia, facial asymmetry and severe headache, besides worsening of previous motor deficits.
The patient symptoms were consistent with acute stroke, so following the hospital protocol based on collaboration between neurology, emergency and clinical laboratory services, stroke alert was called and initiated.  

Being alert and hemodynamically stable during neurological examination, left central facial palsy, slightly dysarthric speech and both left hemiplegia and hemianesthesia were detected.

Abnormal blood test results were drawn to the attention of the staff on call (table 1).

tabla1Table 1. Altered blood test results.

Such a great count of lymphocytes lead the laboratory to carry out a peripheral blood smear and to check the scatterplots for altered patterns (figure 1).

These results led the medical team to admit the patient on the hematology ward and acute stroke alert was interrupted. A diagnosis of ischemic stroke secondary to acute leukemia was made.

tabla2Table 2. Blood test evolution during hospital stay.  Aggravation of the previously altered parameters is shown.

It was decided to avoid invasive procedures (table 2), so bone marrow examination was not carried out and palliative care was provided. The patient succumbed to the disease three days after the episode.

This is an uncommon presentation of acute leukemia. Clinical laboratory contribution was essential, providing the tools to discard the initially suspected acute stroke and to confirm the diagnosis of acute leukemia.

Leukostasis is defined as a complication of acute leukemia associated with a hyperleukocytosis count greater than 50,000/mm3.

It is considered a poor prognostic factor and it is associated with decreased survival as a result of the severity of its consequences, most of them arising out of the adhesion of blast cells to vascular endothelium.

Main organs affected are:
- Central nervous system (CNS): Being brain hemorraghe a main complication.
- Lung: Cursing with hypoxemia, dyspnea and tachypnea, potentially leading to respiratory failure. Interstitial or alveolar infiltrates are often found.

Leukostasis is more frequent in AML than in ALL. In addition, myeloid blasts are larger and have a higher predisposition to endothelium adhesion.

This case constitutes a peculiar one because leukostasis didn’t behave as expected in the patient. The vast quantity of leukocytes in the blood of the patient resulted in brain ischemia due to vascular occlusion, which explains how an acute leukemia was initially diagnosed as an acute ischemic stroke.

REFERENCES
  1. Wellington K, Campos L. Leucostasis cerebral por crisis blástica en leucemia mieloide crónica. Med Hoy. 2017;33 (1):19-22.
  2. Moreno LP, Londono D. Hiperleucocitosis asociada a leucostasis pulmonar y cerebral en leucemia mieloide aguda.  Acta Med Colomb. 2011; 36 (2):90-92.
  3. Shiber JR, Fines RE. Cerebral hemorrhage due to hyperleucocytosis. Journal of Emergency medicine. 2008; 40(6):674-677.
  4. González AI, Rebolledo AM, Fonseca DL. Paciente con livideces en miembros inferiores y leucemia mieloide aguda. 2007; 15(3):232-234.

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