A four year old boy was admitted with a history of abdominal pain and fever for two months maculopapular rash for ten days, and dry cough, dyspnea and wheezing for three days. One examination liver and spleen were enlarged 4 cm and 3 cm respectively below the costal margins. His hemoglobin was 10.0 g/dl, platelet count 37 x 109/L and total leukocyte count 70 x 109/L, which included 80% eosinophils Bone marrow examination revealed a cellular marrow comprising of 45% blasts and 34% Eosinophils and eosinophilic precursors. The blasts stained negative for myeloperoxidase and non-specific esterase and were positive for CD19, CD10, CD22 and CD20. Which one of the following is the most likely diagnosis -
Ans. is 'c' i.e., Acute lymphoblastic leukemia with hypereosinophilic syndrome The cytochemical features of the blast Myeloperoxidases negative Non specific esterase ---> negative Both myeloperoxidaes and nonspecific esterases are positive in cells of myeloid origin and are negative in cellsoflymphoid origin. Remember, myeloid lineage includes eosinophil, neutrophil and basophils . So the blasts found in the bone marrow are of lymphoid origin (not of myeloid) according to cytochemistry Presence of Pan B cell (CD 19, CD I0, CD22) markers also confirm the cell of lymphoid origin (B lymphocytes) Now let us see the options Acute eosinophilic leukemia For the diagnosis of acute eosinophilic leukemia, the blast cells present in the bone marrow should be of eosinophilic lineage (In these case it is of lymphoid lineage.) Acute myeloid leukemia with eosinophilia It can be ruled out because blasts are not of myeloid lineage which is essential for the diagnois of myeloid leukemia. Biphenotypic acute leukemia (lymphoid and eosinophil lineage) o For the diagnosis of biphenotypic leukemia, blast cell of two lineage must be present In this case blast cells of only lymphoid lineages are present So we are left with option 'c' which is the diagnosis in this case. In ALL with hypereosinophilic syndrome, the symptoms of eosinophilia usually preceedes the symptoms of ALL.
Biphenotypic acute leukemia (lymphoid and eosinophil lineage)Acute eosinophilic leukemia)
Acute lymphoblastic leukemia with hypereosinophilic syndrome
Acute myeloid leukemia with eosinophilia
All