An acute leukemia with two faces

A 5-year old girl visited the emergency ward complaining about fatigue and weight loss. The GP found a normocytic anemia (Hb 4,1 mmol/l). For children Hb ref-range is 6.0-9.0 mmol/L.

The peripheral blood film showed a mild leucopenia (2, 7 x 10 9/l); a lymphocytosis and 1% erythroblasts. Due to the anemia, the patient received an erythrocyte-transfusion. Virus serology (EBV, CMV, mycoplasma, Parvovirus B19) turned out to be negative. After transfusion the patient felt better, Hb normalized and the leucopenia had resolved spontaneously, the peripheral blood film showed no abnormalities. Her previous anemia and leucopenia were therefore contributed to a post viral status. She was discharged from further follow-up and her parents were informed to take renewed contact if symptoms recurred.

A few weeks later the patient came back with pain in hip, neck and thorax. The peripheral blood film showed 12% blasts. Images A and B captured on a CellaVision DM96.


Flowcytometry analysis showed CD13 and CD33 positivity of the blast population (CD10+19+20). Subsequent cytogenetic analysis showed in addition to a complex aberrant genotype, the presence of t(12;21)(p13;q22) (TEL-AML1; ETV6-RUNX1).

This cytogenetic abnormality is associated with CD13/33-positivity in acute lymphoblastic leukemia (ALL). The patient was referred to an academic hospital
for further treatment and analysis.

Thanks to Anne de Grauw, Kathleen Welborn, Warry van Gelder and Jürgen Riedl, Albert Schweitzer Hospital, Dordrecht, the Netherlands who shared this interesting patient case.


4 thoughts on “An acute leukemia with two faces”

  1. Noting Lab findings provided, 1. Bicytopenia , no mention of Platetets, , all serology NAD, marked drop in Hb, no reticulocyte count but B19 Negative , so exclude PRCA .
    Assuming Low platelet , will make this a case of Pancytopenia, this then needs further investigation then discharge the patient . Paediatric morphology needs a very carefully done blood film, most preferably traditional microscope rather then cell a vision.

  2. Dear Jurgen Riedl,
    Can you tell me the result of the peripheral blood film of the first visit (emergency ward). Virus serology turned out to be negative, so you may excluded a viral infection? I understand that all the lymphocytes had an normal morphological features
    during her first visit.

  3. An interesting case. Was the platelet count reduced at the first admission ? If the platelet count was low and given the extememely low Hb, low leucocyte count and NRBC’s we would have done a bone marrow to exclude an abnormality. An increased number of blast cells would have been present at this admission I am sure.
    Lab Scientist – Haematology

  4. I would like to see the first blood smear when the WBC was 2.7 k/uL. And see if there were occasional blast, but were not detected.

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