A Patient with Acute Erythroid Leukemia with Granular Leukemic Cells Mimicking Megakaryoblast
A 57-years-old male patient presented to the hospital complaining of chest tightness, dyspnea, fatigue, and loss of appetite. Initial hematological results revealed a total leukocyte count of 2.42 × 109/L, erythrocyte count of 1.26 × 1012/L, hemoglobin of 43 g/L, and platelets of 76 × 109/L. Peripheral blood smear was not significant. Bone marrow examination revealed infiltration by 46% of granular leukemic cells with large size mimicking megakaryoblast. And these megakaryoblast-like leukemic cells had large round nuclei, immature chromatin, prominent nucleolus, and high nuclear-to-cytoplasmic ratios (Fig. 1A). Moreover, these blasts were also characterized by the cytoplasmic granules with pseudopodia and vacuoles (Fig. 1B). And myeloperoxidase was negative for these cells (Fig. 1C). Moreover, periodic-acid Schiff staining showed strongly positive with a granular pattern on these blasts (Fig. 1D). Then the megakaryocytic leukemia was highly suspected on this patient. However, further bone marrow immunophenotypes by flow cytometry were positive for CD36 (Fig. 1E), CD71 (Fig. 1F), CD105, HLA-DR, CD34 CD117, CD58, CD4, CD38 and CD33, and negative for GlyA, CD41a, CD42b, CD61, MPO, CD14, CD64, CD2, CD3, CD5, CD7, CD8, CD10, CD11b, CD13, CD15, CD16, CD19, CD20, CD22, CD56, CD123, cCD79a, TdT and cCD3 on blast cells, exclude lymphocyte or megakaryocyte phenotype. Moreover, positive E-Cadherin staining on the bone marrow further supports the erythroid lineage. Thus, these findings were consistent with acute erythroid leukemia (AEL) with morphological features resembling the megakaryoblast. Meanwhile, cytogenetics showed a normal male karyotype, but genomic sequencing analysis revealed pathogenic mutations on TP53, KMT2D, and SETD2. Finally, AEL was diagnosed in this patient.
Fig. 1.
A patient with pure erythroid leukemia with granular leukemic cells mimicking megakaryoblast. Wright-Giemsa stained bone marrow aspirate smears revealed that cluster of blast cells have round nuclei with immature chromatin and prominent nucleolus (1000×) A, and pseudopodia cytoplasm with granules and vacuoles (1000×) B. The myeloperoxidase C and periodic-acid Schiff D staining of the bone marrow aspirate smears in this patient (1000×). The bone marrow immunophenotypes by flow cytometry were positive for CD36 E, and CD71 F on these blast cells
AEL is characterized by ≥ 30% of immature erythroid cells (proerythroblasts) in bone marrow with erythroid predominance, usually ≥ 80% of cellularity [1]. Moreover, the occurrence of AEL cases in which nucleated erythroid cells constitute less than 80% of bone marrow cellularity is recognized [2]. The morphology of erythroid lines is usually characterized by the lack of cytoplasmic granules. However, this AEL case with granular leukemic cells mimicking megakaryoblast reminds us that morphology may be misleading in specific situations. Such cases should be promptly diagnosed with awareness of this morphologic pitfall, and proper application of ancillary flow cytometry, cytochemical staining, and genomic analysis could avoid the misdiagnosis.
Acknowledgments
None.
Author Contributions
Zhaoliang Wang provide the picture and clinical data and wrote the manuscript. JG ananlyzed the data. JL wrote the manuscript.
Funding
Project supported by Hainan Province Clinical Medical Center.
Data Availability
This study did not involve the personal information, only report the laboratory data. Then the patient consent was waived, and this waive was approved by Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical College, China.
Declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
This study has approved by the ethical committee of Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical College, China.
Consent to Participate
This study did not involve the personal information, only report the laboratory data.Then the patient consent was waived, and this waive was approved by Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical College, China.
Footnotes
Zhaoliang Wang and Jiaquan Guo have equally contributed this work.
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References
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Data Availability Statement
This study did not involve the personal information, only report the laboratory data. Then the patient consent was waived, and this waive was approved by Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical College, China.