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A 67-year-old male presents for further evaluation secondary to persistent bleeding from a hyperpigmen ted lesion on the hard palate that had been biopsied 5 days previ-ously (shown below).
Patien t reports having good health with no sign i fican t prior medical h istory. Evaluation reveals leu kocyte count of 2.1 00/pl, ANC 800/pl, hemoglobin of 8.2/d l, and platelet count of 82 .000/ pl. PT and PTT are prolonged . I mages of the peripheral blood smear and bone marrow aspirate are shown below.
What is the most likely diagnosis?
- Acute lymphocytic leukemia (ALL)
- Acute myeloid leukemia (AML)
- Acute promyelocytic leukemia (APL)
- Thrombotic thrombocytopenic purpura (TTP)
- Sepsis
Medicine
C. The peripheral blood smear shows a hypergranular leukocyte with multiple Auer rods ("faggot cell"), while the bone marrow reveals increased promyelocytes with numerous cytoplasmic granules, and a few cells exhibit multiple Auer rods. This presentation with bleeding, pancytopenia, coagulation abnormalities, and the presence of multiple Auer rods is highly suspicious for hypergranular acute promyelocytic leukemia (APL). FISH for t(15; 1 7) was positive and hence confirmed a diagnosis of hypergranular APL. APL constitutes 5% to 8% of AML, and the hypergranular variant accounts for 60% to 70% of cases and usually presents with leukopenia. The t(15;17) results in the fusion of the PML gene with the retinoic acid receptor (RARA) gene. APL is a specific subclass of AML classified as AML with t( 1 5; 1 7) by the WHO classification and as AML-M3 under the old FAB classification (Br J Haematol.
20 12;156(1):24).
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