The Strange Case of Dr Jekyll and Mr Hyde
An 18-year-old male was examined in the emergency room of one of our hospital locations. He was referred by his GP because of general discomfort and abdominal pain. The patient had no fever, no night sweats and no weight loss. Physical examination revealed lymphadenopathy in neck, axilla and inguinal area; otherwise no significant findings. Laboratory investigations showed a normal hemoglobin level (10.8 mmol/L; 17.4 g/dL), a mild thrombocytopenia (120 x 109/L) and a normal leukocyte count. The lactate dehydrogenase level was elevated (1973 U/L, reference range: <450 U/L). Morphological analysis showed 10% blasts. The images A and B below were captured on a CellaVision DM96.
Subsequent flowcytometric analysis of both peripheral blood and bone marrow showed the blast population to be positive for CD34, CD45, CD13, CD33, MPO, cytCD3, CD5 (weak), CD19 (weak), CD79a and CD7. The blasts were negative for TdT and CD10. Cytogenetic analysis revealed a complex aberrant karyotype. This multidisciplinary approach led to the diagnosis of an MPAL, type T/Myeloid. The patient was transferred to an academic hospital for treatment in a clinical trial setting.
Thanks to Rob Castel and Jürgen Riedl, GKCL, Albert Schweitzer Hospital, Dordrecht, Netherlands for sharing this strange case.