doi:10.1111/ejh.12236
European Journal of Haematology 92 (458)
CLINICAL PICTURE
Chronic myeloid leukemia in lymphoid blast crisis
Brief case description
Author’s contribution
A 74-year-old man was admitted with a 4-month history of unintentional weight loss, intermittent epigastric pain, and marked leukocytosis that was discovered during treatment for lower extremity cellulitis. Complete blood counts revealed a leukocyte count of 269 9 109/L with 48% neutrophils, 8% lymphocytes, 1% monocytes, 5% eosinophils, 1% basophils, 5% immature granulocytes, and 32% blasts, a hemoglobin of 9.4 g/dL with 5% nucleated red blood cells, and a platelet count of 450 9 109/L (A). Immunophenotyping by flow cytometry showed expression of CD19, CD33, CD34, CD45, CD79a, CD123, and TdT without MPO or CD117 on blasts. Surprisingly, the bone marrow aspirate smears demonstrated an overall blast percentage approximating 10% (B). However, small foci of abnormal blasts were seen embedded in the periosteum (C); they were uniformly positive for TdT (D), PAX5, and CD34. Metaphase analyses revealed a t(9;22) (q34;q11.2) in 20/20 cells, with deletion of chromosome 7 as additional abnormality in 5/20 cells; of note, FISH performed on maturing myeloid cells showed a normal result for chromosome 7, whereas 86% of CD19+ blasts demonstrated a monosomy 7. Overall, these findings were consistent with B-lymphoid blast crisis of CML, with loss of chromosome 7 as secondary abnormality during the transformation process.
S.C. and R.B.W. are responsible for the conception and writing of this clinical vignette.
458
Conflict of interest
S.C. and R.B.W. declare no competing financial interests.
Sindhu Cherian1, Roland B. Walter2,3,4 1 Department of Laboratory Medicine, Division of Hematopathology, University of Washington, Seattle, WA; 2Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle,WA; 3Department of Medicine, Division of Hematology, University of Washington, Seattle, WA; 4Department of Epidemiology, University of Washington, Seattle, WA, USA Correspondence Roland B. Walter, MD, PhD, Clinical Research Division, Fred Hutchinson Cancer Research Center; 1100 Fairview Ave N, D2-190; Seattle, WA 98109-1024, USA. Tel: +1 206 667 3599; Fax: +1 206 667 5255; e-mail: [email protected]
A
B
C
D
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
European Journal of Haematology 92 (458)
CLINICAL PICTURE
Chronic myeloid leukemia in lymphoid blast crisis
Brief case description
Author’s contribution
A 74-year-old man was admitted with a 4-month history of unintentional weight loss, intermittent epigastric pain, and marked leukocytosis that was discovered during treatment for lower extremity cellulitis. Complete blood counts revealed a leukocyte count of 269 9 109/L with 48% neutrophils, 8% lymphocytes, 1% monocytes, 5% eosinophils, 1% basophils, 5% immature granulocytes, and 32% blasts, a hemoglobin of 9.4 g/dL with 5% nucleated red blood cells, and a platelet count of 450 9 109/L (A). Immunophenotyping by flow cytometry showed expression of CD19, CD33, CD34, CD45, CD79a, CD123, and TdT without MPO or CD117 on blasts. Surprisingly, the bone marrow aspirate smears demonstrated an overall blast percentage approximating 10% (B). However, small foci of abnormal blasts were seen embedded in the periosteum (C); they were uniformly positive for TdT (D), PAX5, and CD34. Metaphase analyses revealed a t(9;22) (q34;q11.2) in 20/20 cells, with deletion of chromosome 7 as additional abnormality in 5/20 cells; of note, FISH performed on maturing myeloid cells showed a normal result for chromosome 7, whereas 86% of CD19+ blasts demonstrated a monosomy 7. Overall, these findings were consistent with B-lymphoid blast crisis of CML, with loss of chromosome 7 as secondary abnormality during the transformation process.
S.C. and R.B.W. are responsible for the conception and writing of this clinical vignette.
458
Conflict of interest
S.C. and R.B.W. declare no competing financial interests.
Sindhu Cherian1, Roland B. Walter2,3,4 1 Department of Laboratory Medicine, Division of Hematopathology, University of Washington, Seattle, WA; 2Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle,WA; 3Department of Medicine, Division of Hematology, University of Washington, Seattle, WA; 4Department of Epidemiology, University of Washington, Seattle, WA, USA Correspondence Roland B. Walter, MD, PhD, Clinical Research Division, Fred Hutchinson Cancer Research Center; 1100 Fairview Ave N, D2-190; Seattle, WA 98109-1024, USA. Tel: +1 206 667 3599; Fax: +1 206 667 5255; e-mail: [email protected]
A
B
C
D
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
