A 29 y.o. woman presents with HA , fever and fatigue

She was noted to have an elevated WBC count and Hgb of 5.

What do you notice on her peripheral smear?

Our patient had B cell  acute lymphoblastic leukemia. How do you tell a lymphoblast from a myeloblast

in the peripheral smear?

myeloblasts have more cytoplasm and may have auer rods.

EMERGENCIES THAT CAN OCCUR IN ACUTE LEUKEMIA

1.       Tumor lysis syndrome- This can occur before starting treatment as a result of high turn over of malignant cells. The laboratory definition includes two or more abnormal lab values of uric acid, potassium, phosphorus or calcium  at presentation. Clinically,  renal dysfunction, seizures, cardiac arrhythmias or sudden death may occur.  The treatment is hydration, correction of uric acid levels and electrolyte correction.  Often 5 L /day is required to maintain a urine output of 100ml/hour.  Rasburicase  is used prophylactically to reduce uric acid. (rasburicase cannot be used in G6PD patients)

2.       Hyperleukocytosis- Large numbers of WBCs block blood vessels causing pulmonary infarcts with hypoxia and strokes.  Usually the WBC count is > 100,000. Blood transfusions can add to the problem. Leukapheresis is often needed.

3.       DIC – can occur with acute promyelocytic leukemia . This occurs in 20% of AML. This leukemia presents with a LOW Wbc count,  and few circulating blasts.  The marrow is packed with blasts. Trans retinoic acid must be started immediately.  This leukemia is a worry in any pancytopenic patient.

promyelocytes have large granules

Our patient had a Philadelphia chromosome which is usually associated with CML.

Our patient’s WBC was 182,000 with hgb of 5.2,and plts of 45. She underwent leukapheresis x two followed by induction therapy with hyper CVAD( cyclophosphamide, vincristine, doxorubicin and dex)  and dasatinib.  She developed septic shock and  grew strep salivarius/mitis. She also had klebsiella pneumonia.  She recovered and was discharged 3 weeks after admission. Her WBC was 4.2.

A review of blood cell differentiation

Zuckerman T, Ganzel C, Tallman M, Rowe J.  How I treat hematologic emergencies in adults with acute leukemia. Blood.  2012 120;1993-2002.

Fielding A,  Current treatment of Philadelphia chromosome-positive acute lymphoblastic  leukemia. Haematologica 2010. Jan;95(1) 8-12.

Ribera  J, Oriol  A,  Gonzalez  M, et al. Concurrent intensive chemotherapy and imatinib before and after stem  cell transplantation in newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukemia. final  results  of the CSTIBES02 trial. Haematologica. 2010;95(1):87-95.                                                                                                                                                                                                                                                                                                                                       

auer rods are found in myelogenous leukemia