Brief Communication Acta Haematol 2015;133:321–323 DOI: 10.1159/000366095
Received: July 2, 2014 Accepted after revision: July 19, 2014 Published online: December 2, 2014
Multiple Pseudo-Chediak-Higashi Inclusions Associated with MYC Deletion in a Patient with Acute Myeloid Leukemia Maria Teresa Vargas Virginia Escamilla Rosario M. Morales-Camacho Concepcion Prats Teresa Caballero-Velázquez Ricardo Bernal Jose A. Pérez Simón
Key Words Pseudo-Chediak-Higashi inclusions · Acute myeloid leukemia · C-MYC deletion
The morphologic hallmark of Chédiak-Higashi syndrome, a rare autosomal recessive disorder characterized by increased fusion of cytoplasmic granules and cellular dysfunction, is the presence of giant granules in neutrophils, lymphocytes and monocyte cytoplasm. The pseudo-Chédiak-Higashi (PCH) anomaly is a large pink or purple cytoplasmic granule that has only been rarely described in acute myeloid leukemia (AML) [1–9]. These giant granules are azurophilic and myeloperoxidase positive. Electron microscopy has demonstrated small vesicles in the cytoplasm near the giant granules suggesting that their origin might be related to the pathology fusion of primary granules and/or small, dense vesicles [9]. The MYC abnormalities such as amplifications, translocations, mutations and chromosome rearrangements have been described in different solid tumors, leukemia and lymphoma. Coexistence of PCH and MYC gene amplification in double-minute chromosomes has been previously reported in 3 patients with AML M2 [5]. The MYC oncogene has been shown to be amplified in sev© 2014 S. Karger AG, Basel 0001–5792/14/1334–0321$39.50/0 E-Mail [email protected] www.karger.com/aha
eral but not all cases of AML with double-minute chromosomes and has been associated with resistance and disease aggressiveness [10]. In a review of the literature we did not find an association of multiple pseudo-ChediakHigashi inclusions with MYC deletion. A 74-year-old retired mine worker presented with weakness, weight loss and fever with respiratory symptoms for 2 months. On physical examination there was neither hepatosplenomegaly nor lymphadenopathy. Blood counts showed hemoglobin 13.0 g/dl, MCV 102 fl, platelets 41 × 109/l and leukocytes 36.7 × 109/l. Peripheral blood stained with May-Grünwald-Giemsa at pH 6.4 showed 58% blasts with Auer rods (10%) and multiple giant inclusions (0.3%). Bone marrow aspirate was hypercellular with 57% blasts and 16% maturing cells of neutrophil lineage. He was diagnosed with M2 AML (FAB)/ AML with maturation (WHO). Some bone marrow leukemic cells presented unique and long Auer rods (2%), and others (0.5%) showed multiple rounded pink-colored inclusions up to 4 μm in diameter (fig. 1, 2), strangely unique (fig. 2c) and exceptionally associated with Auer rods (fig. 1a). The inclusions exhibited strong enzyme activity for myeloperoxidase (fig. 2b) and positivity with Sudan Black B staining (fig. 2d). These findings were consistent with the PCH anomaly. Maria Teresa Vargas, MD UGC of Hematology, Instituto de Biomedicina de Sevilla (IBIS) Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla Av. Manuel Siurot s/n., ES–41013 Seville (Spain) E-Mail mtvargas @ us.es
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/3/2014 12:16:59 AM
UGC of Hematology, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/ Universidad de Sevilla, Seville, Spain
Color version available online
b
c
d
a
b
c
d
Fig. 2. Bone marrow smear. a, c Leukemic cells showing pink-colored inclusions (May-Grünwald-Giemsa stain, ×1,000). b Multiple PCH inclusions with strong positive myeloperoxidase stain. d Positivity with Sudan Black B stain.
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Acta Haematol 2015;133:321–323 DOI: 10.1159/000366095
Vargas et al.
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/3/2014 12:16:59 AM
Color version available online
Fig. 1. Bone marrow smear (May-Grünwald-Giemsa stain, ×1,000). Leukemic cells showing multiple pink-colored inclusions (a–d) exceptionally associated with Auer rods (a).
a
Color version available online
Fig. 3. Metaphase and interphase FISH showing the deletion of C-MYC (orange).
Flow cytometry demonstrated blasts positive for CD45, CD34, CD117, MPO, CD38, HLA-DR, CD13, CD33 and CD64, and negative for any other B, T or myeloid markers. Chromosome analysis was performed at diagnosis on bone marrow with short-term nonstimulated cultures, according to standard procedures; at least 20 metaphases were analyzed to exclude clonal abnormalities. Karyo-
types were described according to the International System for Human Cytogenetic Nomenclature (ISCN) 2013 [11]. Cytogenetic analysis revealed a normal karyotype: 46,XY (20). FISH analyses were carried out following standard procedures on fixed cells to detect. The probe set consisted of CEP 8(aqua)/MYC(red)/IGH(green) (Abbott Molecular Inc., Des Plaines, Ill., USA). The number of metaphase and interphase cells analyzed ranged from 100 to 400. The interphase cutoff value was 10%. Metaphase and interphase FISH using a CEP(aqua)/MYC(red)/ IGH(green) probe set showed one chromosome 8 without MYC signal (fig. 3), thus confirming the deletion of MYC. The patient received best supportive care and died due to pneumonia and sepsis 11 months after diagnosis. Giant cytoplasmic inclusions in AML, resembling those seen in the Chediak-Higashi syndrome, are called the PCH anomaly and are seldom observed. Coexistence of this anomaly and MYC gene amplification in doubleminute chromosomes have been reported in 3 patients with AML M2 [5]. On the other hand, in the revised literature, no reports have been found that describe the simultaneous PCH anomaly and MYC gene deletion. PCH is a rare and interesting morphologic finding in acute leukemia. Its exact biological significance, however, still remains largely unknown.
References
AML with Pseudo-Chediak-Higashi Inclusions and C-MYC Deletion
5 Golovleva I, Hultdin J, Roos G, Wahlin A, Holgrem G: Coexistence of pseudo–ChédiakHigashi anomaly and double minutes containing c-myc oncogene in three patients with AML M2. Leukemia 2002;16:152–154. 6 Bozkaya IO, Yarali N, Sac RU, Tavil B, Kara A, Azik F, Tunç B: Pseudo-Chediak-Higashi anomaly in acute myeloid leukemia with t (8; 21). J Pediatr Hematol Oncol 2012;34:242. 7 Abdulsalam AH, Sabee N, Bain BJ: PseudoChédiak-Higashi inclusions together with Auer rods in acute myeloid leukemia. Am J Hematol 2011;86:602.
8 Kakkar N, Das S, Joseph JM: Pseudo Chediak Higashi inclusions in a patient with acute myeloblastic leukemia. Indian J Cancer 2010;47: 81–82. 9 Hamanaka SC, Gilbert CS, White DA, Parmely RT: Ultrastructure morphology, cytochemistry, and morphometry of eosinophil granules in Chédiak-Higashi syndrome. Am J Pathol 1993;143:618–627. 10 Fegan CD, White D, Sweeney M: C-myc amplification, double minutes and homogenous staining regions in a case of AML. Br J Haematol 1995;90:486–488. 11 Shaffer LG, Slovak ML, Campbell LJ (eds): ISCN (2013): An International System for Human Cytogenetic Nomenclature. Basel, Karger, 2013.
Acta Haematol 2015;133:321–323 DOI: 10.1159/000366095
323
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/3/2014 12:16:59 AM
1 Gallardo R, Kranwinkel RN: Pseudo-Chédiak-Higashi anomaly. Am J Clin Pathol 1985;83:127–129. 2 Symes PH, Williams ME, Flessa HC, Srivastava AK, Swerdlow SH: APL with pseudoChédiak-Higashi anomaly and molecular documentation of t(15; 17) chromosomal translocation. Am J Clin Pathol 1993;99:622– 627. 3 Markovic N: Chédiak-Higashi-like granules in acute promyelocytic leukemia. Blood 1998; 92:3475–3477. 4 Powari M, Varma N, Varma S, Komal HS: Pseudo-Chédiak Higashi anomaly in an Indian patient with acute myeloid leukemia (AML-M2). Am J Hematol 2000; 65: 324– 325.
Received: July 2, 2014 Accepted after revision: July 19, 2014 Published online: December 2, 2014
Multiple Pseudo-Chediak-Higashi Inclusions Associated with MYC Deletion in a Patient with Acute Myeloid Leukemia Maria Teresa Vargas Virginia Escamilla Rosario M. Morales-Camacho Concepcion Prats Teresa Caballero-Velázquez Ricardo Bernal Jose A. Pérez Simón
Key Words Pseudo-Chediak-Higashi inclusions · Acute myeloid leukemia · C-MYC deletion
The morphologic hallmark of Chédiak-Higashi syndrome, a rare autosomal recessive disorder characterized by increased fusion of cytoplasmic granules and cellular dysfunction, is the presence of giant granules in neutrophils, lymphocytes and monocyte cytoplasm. The pseudo-Chédiak-Higashi (PCH) anomaly is a large pink or purple cytoplasmic granule that has only been rarely described in acute myeloid leukemia (AML) [1–9]. These giant granules are azurophilic and myeloperoxidase positive. Electron microscopy has demonstrated small vesicles in the cytoplasm near the giant granules suggesting that their origin might be related to the pathology fusion of primary granules and/or small, dense vesicles [9]. The MYC abnormalities such as amplifications, translocations, mutations and chromosome rearrangements have been described in different solid tumors, leukemia and lymphoma. Coexistence of PCH and MYC gene amplification in double-minute chromosomes has been previously reported in 3 patients with AML M2 [5]. The MYC oncogene has been shown to be amplified in sev© 2014 S. Karger AG, Basel 0001–5792/14/1334–0321$39.50/0 E-Mail [email protected] www.karger.com/aha
eral but not all cases of AML with double-minute chromosomes and has been associated with resistance and disease aggressiveness [10]. In a review of the literature we did not find an association of multiple pseudo-ChediakHigashi inclusions with MYC deletion. A 74-year-old retired mine worker presented with weakness, weight loss and fever with respiratory symptoms for 2 months. On physical examination there was neither hepatosplenomegaly nor lymphadenopathy. Blood counts showed hemoglobin 13.0 g/dl, MCV 102 fl, platelets 41 × 109/l and leukocytes 36.7 × 109/l. Peripheral blood stained with May-Grünwald-Giemsa at pH 6.4 showed 58% blasts with Auer rods (10%) and multiple giant inclusions (0.3%). Bone marrow aspirate was hypercellular with 57% blasts and 16% maturing cells of neutrophil lineage. He was diagnosed with M2 AML (FAB)/ AML with maturation (WHO). Some bone marrow leukemic cells presented unique and long Auer rods (2%), and others (0.5%) showed multiple rounded pink-colored inclusions up to 4 μm in diameter (fig. 1, 2), strangely unique (fig. 2c) and exceptionally associated with Auer rods (fig. 1a). The inclusions exhibited strong enzyme activity for myeloperoxidase (fig. 2b) and positivity with Sudan Black B staining (fig. 2d). These findings were consistent with the PCH anomaly. Maria Teresa Vargas, MD UGC of Hematology, Instituto de Biomedicina de Sevilla (IBIS) Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla Av. Manuel Siurot s/n., ES–41013 Seville (Spain) E-Mail mtvargas @ us.es
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/3/2014 12:16:59 AM
UGC of Hematology, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/CSIC/ Universidad de Sevilla, Seville, Spain
Color version available online
b
c
d
a
b
c
d
Fig. 2. Bone marrow smear. a, c Leukemic cells showing pink-colored inclusions (May-Grünwald-Giemsa stain, ×1,000). b Multiple PCH inclusions with strong positive myeloperoxidase stain. d Positivity with Sudan Black B stain.
322
Acta Haematol 2015;133:321–323 DOI: 10.1159/000366095
Vargas et al.
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/3/2014 12:16:59 AM
Color version available online
Fig. 1. Bone marrow smear (May-Grünwald-Giemsa stain, ×1,000). Leukemic cells showing multiple pink-colored inclusions (a–d) exceptionally associated with Auer rods (a).
a
Color version available online
Fig. 3. Metaphase and interphase FISH showing the deletion of C-MYC (orange).
Flow cytometry demonstrated blasts positive for CD45, CD34, CD117, MPO, CD38, HLA-DR, CD13, CD33 and CD64, and negative for any other B, T or myeloid markers. Chromosome analysis was performed at diagnosis on bone marrow with short-term nonstimulated cultures, according to standard procedures; at least 20 metaphases were analyzed to exclude clonal abnormalities. Karyo-
types were described according to the International System for Human Cytogenetic Nomenclature (ISCN) 2013 [11]. Cytogenetic analysis revealed a normal karyotype: 46,XY (20). FISH analyses were carried out following standard procedures on fixed cells to detect. The probe set consisted of CEP 8(aqua)/MYC(red)/IGH(green) (Abbott Molecular Inc., Des Plaines, Ill., USA). The number of metaphase and interphase cells analyzed ranged from 100 to 400. The interphase cutoff value was 10%. Metaphase and interphase FISH using a CEP(aqua)/MYC(red)/ IGH(green) probe set showed one chromosome 8 without MYC signal (fig. 3), thus confirming the deletion of MYC. The patient received best supportive care and died due to pneumonia and sepsis 11 months after diagnosis. Giant cytoplasmic inclusions in AML, resembling those seen in the Chediak-Higashi syndrome, are called the PCH anomaly and are seldom observed. Coexistence of this anomaly and MYC gene amplification in doubleminute chromosomes have been reported in 3 patients with AML M2 [5]. On the other hand, in the revised literature, no reports have been found that describe the simultaneous PCH anomaly and MYC gene deletion. PCH is a rare and interesting morphologic finding in acute leukemia. Its exact biological significance, however, still remains largely unknown.
References
AML with Pseudo-Chediak-Higashi Inclusions and C-MYC Deletion
5 Golovleva I, Hultdin J, Roos G, Wahlin A, Holgrem G: Coexistence of pseudo–ChédiakHigashi anomaly and double minutes containing c-myc oncogene in three patients with AML M2. Leukemia 2002;16:152–154. 6 Bozkaya IO, Yarali N, Sac RU, Tavil B, Kara A, Azik F, Tunç B: Pseudo-Chediak-Higashi anomaly in acute myeloid leukemia with t (8; 21). J Pediatr Hematol Oncol 2012;34:242. 7 Abdulsalam AH, Sabee N, Bain BJ: PseudoChédiak-Higashi inclusions together with Auer rods in acute myeloid leukemia. Am J Hematol 2011;86:602.
8 Kakkar N, Das S, Joseph JM: Pseudo Chediak Higashi inclusions in a patient with acute myeloblastic leukemia. Indian J Cancer 2010;47: 81–82. 9 Hamanaka SC, Gilbert CS, White DA, Parmely RT: Ultrastructure morphology, cytochemistry, and morphometry of eosinophil granules in Chédiak-Higashi syndrome. Am J Pathol 1993;143:618–627. 10 Fegan CD, White D, Sweeney M: C-myc amplification, double minutes and homogenous staining regions in a case of AML. Br J Haematol 1995;90:486–488. 11 Shaffer LG, Slovak ML, Campbell LJ (eds): ISCN (2013): An International System for Human Cytogenetic Nomenclature. Basel, Karger, 2013.
Acta Haematol 2015;133:321–323 DOI: 10.1159/000366095
323
Downloaded by: UCSF Library & CKM 169.230.243.252 - 12/3/2014 12:16:59 AM
1 Gallardo R, Kranwinkel RN: Pseudo-Chédiak-Higashi anomaly. Am J Clin Pathol 1985;83:127–129. 2 Symes PH, Williams ME, Flessa HC, Srivastava AK, Swerdlow SH: APL with pseudoChédiak-Higashi anomaly and molecular documentation of t(15; 17) chromosomal translocation. Am J Clin Pathol 1993;99:622– 627. 3 Markovic N: Chédiak-Higashi-like granules in acute promyelocytic leukemia. Blood 1998; 92:3475–3477. 4 Powari M, Varma N, Varma S, Komal HS: Pseudo-Chédiak Higashi anomaly in an Indian patient with acute myeloid leukemia (AML-M2). Am J Hematol 2000; 65: 324– 325.
