PMC8184649_01
Histology. (A): Peripheral blood smear Romanowsky stained slide showing immature promonocyte forms with irregular and delicately convoluted nuclear configuration (original magnification x 400). (B): Flow cytometry showing cell populations preliminarily identified by cytoplasmic complexity (side scatter [SSC], displayed on the x-axis) and CD45 expression (displayed on y-axis); expanded blast/myeloid precursor (circled in red) and monocytic (circled in blue) regions are present. (C): Bone marrow biopsy, hematoxylin & eosin (H&E) stained section slide, medium power view showing bone marrow hypercellularity (90-100%) with increase predominance of blast forms (original magnification x 50). (D). Bone marrow biopsy, H&E section slide, High power view showing blasts with high nuclear:cytoplasmic (N:C) ratios, irregular nuclear contours, fine nuclear chromatin and scant cytoplasm (original magnification x 400). (E): Liver biopsy, H&E stained section slide, medium power view showing mild steatosis of the liver (sides) with a brisk portal and lobular infiltrate (center) (original magnification x 40). (F): Liver biopsy, H&E stained section slide, high power view showing an infiltrate comprised of atypical mononuclear cells along with bile duct proliferation and portal expansion with edema (original magnification x 200). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.).
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Initial studies revealed leukoerythroblastosis with striking leukocytosis (WBC 115.6 x 103/microL), absolute monocytosis, including immature forms and blasts (60%) (Fig. 1A), anemia (Hgb 9.8 g/dL), normal platelet count (204 x 103/microL), elevated liver function tests (AST 204/L and ALT 244/L), total bilirubin 3.3 mg/dL, direct bilirubin 2.5 mg/dL, and alkaline phosphatase 1082/L. Flow cytometry immunophenotype analysis showed an expansion of myeloid precursor/blast and monocytic regions (Fig. 1B). Bone marrow biopsy and aspirate were diagnostic for AML with monocytic differentiation (82%), dysmegakaryopoiesis and dyserythropoiesis (Fig. 1C and D). A percutaneous liver biopsy showed a brisk portal and lobular infiltrate comprised of atypical mononuclear cells (Fig. 1F and E). In addition, the liver parenchyma showed changes suggestive of large duct obstruction, namely bile duct proliferation and portal expansion with edema (Fig. 1F and E).
CT abdomen scan with contrast. The CT abdomen scan demonstrates hepatomegaly, measuring 20.3 cm (as shown by dotted line), with a likely cyst adjacent to the gallbladder. Gallbladder is distended with wall thickening, pericholecystic fluid and sludge within the gallbladder. The CT abdomen scan also demonstrates splenomegaly, measuring 17.3 cm.
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CT chest, abdomen, and pelvis revealed biliary distension with biliary sludge, biliary wall thickening, pericholecystic fluid, hepatosplenomegaly, and lesions in the spleen and lungs (Fig. 2).