SESSION TITLE: Pleural Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: The common causes of malignant pleural effusion are lung carcinoma, breast carcinoma, lymphoma and ovarian carcinoma.Acute myeloid leukemia presenting with unilateral pleural effusion and pleural fluid showing deposits of leukemic cells is a rare condition.AML M1 type FAB classification accounts for about 15% of overall AML cases.Diagnosis is based on presence of >3% blasts cells positive for myeloperoxidase on bone marrow study.We present a rare case of AML with pleural infiltrates of leukemic cells.
CASE PRESENTATION: 30 year old non-smoker caucasian male was admitted with history of progressive dyspnea and Cough associated with scanty mucoid non foul smelling expectoration and fever associated with chills but no rigors since one month.There was history of loss of appetite without any documentary weight loss.On examination patient was pale and tachypnoeic and was having tachycardia.Supraclavicular lymph node was enlarged on left side.Chest examination revealed findings of right sided pleural effusion.Rest of the systemic examination was normal.On investigations hemoglobin was 6 gm%, TLC- 2,15, 000/cmm and Platelet count-36, 000/cmm.Chest X-ray posteroanterior view was consistent with right sided pleural effusion.FNAC of supraclavicular lymph node revealed reactive hyperplasia and not conclusive.Ultrasound abdomen revealed splenomegaly and peri pancreatic lymphadenopathy.Peripheral smear examination it was observed that premature cells were 90%.Bone marrow aspiration study showed myeloperoxidase positive stain BLASTS CELLS >3% of blast cell population.Accelerated myeloblasts constitutes 90% of marrow nucleated cells.On thoracocentesis pleural fluid was hemorrhagic and analysis revealed exudative fliud with cytology showing leukemic cells in clusters and isolation.Gram stain revealed no pus cells and no bacteria and culture showed no growth.Diagnosis of ACUTE MYELOID LEUKEMIA TYPE M1 WITH EXTRAMEDULLARY INVOLVEMENT(EVIDENT BY THE PLEURAL DEPOSITS OF LEUKEMIC CELLS) was established.In view of spiking temperature and blood parameters,chemotherapy was deferred while patient was started on intravenous Piperacillin -tazobactam and Amikacin and Fluconazole.Despite 3 days on these antibiotics, patient's symptoms worsened temperature continued to spike above 39°C and he became more dyspnoeic but unfortunately on 9th day patient condition worsened and succumbed to the disease.
DISCUSSION: Pleural effusion may be seen as a presentation of a haematological malignancy or as a complication.Among the possible suggested pathogenetic mechanisms are, an extramedullary proliferation of an occult leukemic clone with subsequent metastasis to the bone marrow or a subclinical marrow relapse with consequent seeding to extramedullary site(1).Immunocytologic examination of cells obtained from the pleural effusion,flow cytometry,as well as polymerase chain reaction can contribute to the differential diagnosis. The findings sometimes need to be confirmed by invasive procedures with surgical biopsy (2,3).
CONCLUSIONS: Present case had symptoms and signs of pleural effusion rather than classical AML presentation.Leukemia may present with unusual findings and thus delay the diagnosis and treatment.The diagnosis of leukemia which presented with extramedullary involvement was made straight forward with the examination of pleural fluid.This demonstrates the importance of basic and simple procedures for the diagnosis of diseases including extremely rare cases like the present case.
Reference #1: Dix DB, Anderson RA, Mc Fadden DE, Wadsworth LD. Pleural relapse during hematopoietic remission in childhood acute lymphoblastic leukemia. J Pediatr Hematol Oncol 19: 470-472, 1997.
Reference #2: Horn KD, Penchansky L. Chylous pleural effusions simulating leukemic infiltrate associated with thoracoabdominal disease and surgery in infants. Am J Clin Pathol 111: 99-104, 1999.
Reference #3: Yam LT. Granulocytic sarcoma with pleura involvement: identification of neoplastic cells with cytochemistry. Acta Cytol 29: 63- 66, 1985.
DISCLOSURE: The following authors have nothing to disclose: Niranjan Ananda setty, Hemanth Sethy, Geethanjali Panda, Thitta Mohanty, Jyoti Patnaik, Amith Sreedharan, Sukanta Kodali
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