How Do You Know if You Have Eosinophilic Leukaemia
Am J Case Rep. 2013; fourteen: 143–146.
Eosinophilic presentation of astute lymphoblastic leukemia
Azim Rezamand
aneDepartment of Pediatrics, Tabriz Academy (Medical Sciences), Tabriz, Islamic republic of iran
Ziaaedin Ghorashi
1Department of Pediatrics, Tabriz University (Medical Sciences), Tabriz, Iran
Sona Ghorashi
2Immature Researchers Club, Tabriz Branch, Islamic Azad University, Tabriz, Iran
Nariman Nezami
3Drug Applied Research Center, Tabriz University (Medical Sciences), Tabriz, Iran
4Russell H. Morgan Section of Radiology and Radiological Sciences, The Johns Hopkins Hospital, Baltimore, Medico, U.Southward.A.
Received 2012 October 29; Accepted 2013 Jan 31.
Abstract
Patient: Male person, 5
Main Diagnosis: Rule-out appendicitis
Co-existing Diseases: Astute lymphoblastic leukemia (ALL)
Medication: Chemiotherapy
Clinical Procedure: Breast CT • flow cytometry
Specialty: Pediatrics' oncology • infection diseases
Background:
Leukemias are among the most common childhood malignancies. Astute lymphoblastic leukemia (ALL) accounts for 77% of all leukemias. In rare cases, ALL patients may present with eosinophilia.
Example Report:
Here, a 5-yr onetime boy was admitted to our hospital with a possible diagnosis of appendicitis. This patient'due south consummate blood cell count demonstrated leukocytosis with severe eosinophilia. Following a one-calendar month clinical investigation, 2 bone marrow aspirations, and flow cytometry assay, a diagnosis of acute lymphoblastic leukemia was proposed. Finally, the patient was transferred to the oncology ward to receive standard therapeutic protocol, which resulted in disease remission. After chemotherapy for two years, patient is successfully treated.
Conclusions:
ALL is diagnosed by eosinophilia in rare cases. These patients need immediate diagnosis and intensive therapy due to worsened prognosis of ALL presenting equally hypereosinophilia.
Keywords: acute lymphoblastic leukemia, eosinophilia, eosinophilic myelodysplasia
Background
Eosinophils normally account for only 1–3% of peripheral-blood leukocytes, with an upper normal limit of 350 cells/mm3 of claret. Eosinophilia occurs in a wide diverseness of disorders (meet Tabular array 1), including allergies, parasitic infections in pure hereditary form, and even hematologic and oncologic disorders such as Hodgkin's lymphoma, chronic myeloid leukemia, and pernicious anemia [one,two]. The nearly common cause of eosinophilia worldwide is helminthic infections, and the nigh mutual cause in industrialized nations is atopic disorders [1].
Table ane
Diseases with eosinophilia and differentional diagnosis one.
| Type of disease | Eosinophilia | Examples of causes | |
|---|---|---|---|
| Peripheral blood | Tissue | ||
| Infectious | Nowadays | Present or absent | Infections with peculiarly invasive helminths |
| Respiratory | Present or absent | Present | Eosinophilic pneumonitis, asthma |
| Gastrointestinal | Nowadays or absent-minded | Present | Inflammatory bowel disease, osinophilic, gastroenteritis, allergic colitis |
| Allergic | Present or absent | Present | Allergic rhinoconjunctivitis, asthma, eczema |
| Systemic | Present | Present | Idiopathic hypereosinophilic syndrome, vasculitis |
| Iatrogenic | Present | Nowadays or absent | Drug reaction, cytokine infusions (e.g. granulocyte – macrophage colonystimulating gene) |
| Cancerous | Present or absent | Present or absent-minded | absent Lymphoma, colonic carcinoma |
The differential diagnosis of eosinophilia requires a review of the patient'southward history, which may reveal wheezing, rhinitis, or eczema; travel to endemic areas of helminthic infections; the presence of a pet dog; symptoms of cancer; or drug ingestion (indicating a possible hypersensitivity reaction) [ane].
Additionally, eosinophilia has been reported every bit a rare presentation of acute lymphoblastic leukemia (ALL) [ii]. These leukemias are the about common malignant neoplasms in children, accounting for about 41% of all malignancies that occur in children <15 years of age [3]. ALL accounts for almost 77% of babyhood leukemia cases. Usually, the initial presentation of ALL is nonspecific and relatively brief, and may include anorexia, fatigue, irritability, or intermittent low-class fever. Bone pain or, less often, joint pain, particularly in the lower extremities, may be present. The median leukocyte count at presentation is 33 000/mm3, although 75% of patients have counts <20 000 mmthree; thrombocytopenia is seen in 75% of patients [iii].
Nosotros present the example of a 5-year old boy hospitalized with the possible diagnosis of appendicitis. This patient demonstrated leukocytosis with severe eosinophilia. Following clinical piece of work-ups, a terminal diagnosis of ALL was made.
Case Report
A 5-year old boy came to the emergency department due to acute abdominal pain, nausea, and fever following a common common cold. He was admitted to the surgery ward to rule-out appendicitis.
During the concrete examination and sonographic study, there were no significant findings. However, a white blood jail cell (WBC) count of 56 000/mm3, hemoglobin (Hb) of 12.7 g/dl, platelet (Plat) count of 203 000/mmiii, and starting time-hr erythrocyte sedimentation charge per unit (ESR) of 35 mm/60 minutes were reported on laboratory evaluation. A peripheral blood smear study by an oncologist revealed 68% eosinophilia (Figure 1). A triple stool examination was negative for any type of parasite, aspartate aminotransferase (AST) 41, alanine aminotransferase (ALT) eleven, or lactate dehydrogenase (LDH) 690. A computed tomographic evaluation of the lungs, a bone browse, radiographic evaluation of the long bones, and bone marrow aspiration smear analysis were all normal. Therefore, the child was discharged for outpatient follow-up, despite the leukocytosis (WBC: 56 000/mm3) and 75% eosinophilia.
Smear of peripheral blood. Eosinophilia.
After 15 days, he was readmitted for evaluation of malignancy regarding a coughing and splenomegaly plant during the concrete examination, in add-on to a WBC of 45 600/mm3, 55% eosinophilia, and an ESR of 65 mm/60 minutes. One day later readmission, his complete blood cell count showed a WBC of 54 100/mm3 with 72% eosinophilia, a platelet count of 111 000/mmthree, and an ESR of 52. At this point the 2d bone marrow aspiration was performed.
A light microscopic study revealed lymphoblasts with eosinophiles in the bone marrow smear (Effigy 2). The bone marrow flow cytometry analysis and cellular morphology study report is listed in Tabular array two. The kid'south cough and respiratory distress was evaluated using computed tomography, which demonstrated leukemic infiltration throughout both lungs (Figure iii).
Smear of bone marrow aspiration. Presence of the eosinophiles and lymphoblasts.
Transverse view of lung using computed tomography. Leukemic infiltration is seen.
Table ii
Flow cytometry assay results for the second bone marrow aspiration.
| Marker | Percent |
|---|---|
| CD22 | 89% |
| CD7 | half dozen% |
| CD15 | Neg |
| CD33 | 11% |
| CD19 | 80% |
| CD3 | 9% |
| CD13 | Neg |
| CD10 | 85% |
| CD14 | Neg |
| HLA-DR | 89% |
The patient was transferred to the oncology ward for chemotherapy. Considering the results of the bone marrow flow cytometry analysis, a diagnosis of ALL type pre-B cell was proposed and the standard protocol of chemotherapy for lymphoblastic leukemia was subsequently started. The child went into remission after chemotherapy and follow up for two years, and correct now, he is successfully cured totally.
Discussion
Eosinophilic presentation of ALL is a rarely documented miracle and, until at present, only 44 cases have been reported in the literature [iv]. Hypereosinophilic syndrome has been previously described in allergic diseases, parasitic infections, hematologic and oncologic disorders like Hodgkin'south lymphoma, and lymphoblastic leukemia past Nutman et al. [5].
Eosinophilia in the peripheral blood smear of patients with pre-B cell leukemia has been reported more than ofttimes than other types of leukemia [6]. Most recently, Wilson et al. [6] reported ii cases of pre-B cell ALL that initially presented with prolonged eosinophilia and respiratory distress. Later a period of time, a diagnosis of leukemia was made.
Fellows et al. [7] reported on a 43-year old patient with xiii 400/mm3 eosinophiles in peripheral claret smear, who had a normal platelet count and Hb level and after developed migratory arthritis with periarticular soft-tissue swellings and hepatosplenomegaly. This patient was finally diagnosed as an ALL case. Most usually reported patients with significant eosinophilia and ALL are adults. However, Files et al. [8] reported on an eight-year-sometime male person with hypereosinophilia and Loeffler endocarditis who was diagnosed with ALL afterward three months.
ALL-associated hypereosinophilia was initially described in 1973 past Spitzer and Garson. [9] A literature review shows that among ALL cases there is a stiff male person preponderance, a median age of 14 years (range 2–58) at presentation, and the majority of cases are B-cell in origin [10].
Eosinophilia more often than not precedes the diagnosis of ALL and apace resolves upon induction, merely it characteristically returns with leukemic relapse. The prognosis for ALL and hypereosinophilia is significantly worse than for ALL lonely, with a median survival of 7.5 months. In some reports, eosinophilia preceded the ALL diagnosis by 1 to 9 months [eleven,12]. In comparison to standard definition of ALL, congestive heart failure is the principal cause of increased mortality in patients with ALL and hypereosinophilia [10].
In this case, a 5-twelvemonth-one-time boy, initially admitted to the surgery ward to rule-out appendicitis, was reported to be due to astute intestinal pain following a common common cold. In the primary laboratory evaluation, the patient had leukocytosis with severe eosinophilia. Later i calendar month, a diagnosis of ALL was proposed and so confirmed using os marrow aspiration, peripheral blood smear, and flow cytometry analysis. Afterward, the patient was transferred to the oncology department to receive the standard chemotherapy protocol for ALL. The child went into remission subsequently chemotherapy, and he is now on maintenance therapy, according to his chemotherapy protocol.
Conclusions
Rarely, ALL is diagnosed by eosinophilia presenting with moderately increased WBC and college percent of eosinophils. The prognosis of ALL presenting every bit hypereosinophilia is significantly worse than ALL lonely. Therefore, these patients need firsthand diagnosis and intensive therapy.
Acknowledgments
The authors would similar to give thanks Aida Ahari Lahagh for his kind help and editing the present paper.
Footnotes
Financial disclosure
None.
Disharmonize of involvement
None for all authors.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3715333/
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