PMC9361310_01
Laboratory findings at diagnosis of acute promyelocytic leukemia in patient with HIV. (A) Peripheral blood smear morphological showing the large neoplastic promyelocytes with no azurophilic granules or Auer rods, containing a hypogranular variant typical bilobed or reniform nucleus (black arrow); (B) Cytogenetic analysis by G-banding showed the karyotype: 46,XY,t(15;17)(q22;q21). (C) FISH analysis of interphase nucleus confirming the rearrangement involving the PML/RARA genes indicated by the arrows and a typical nucleus, showing two orange and two green signal patterns; (D-H) Analysis by flow cytometry showed: (D) The relationship between cell size and its complexity; (E) CD45 showing hypergranularity; (F) High expression of CD33 on blast cells; (G) Overexpression of CD13 in the blast population. (H) Partial expression of CD117 on blast cells; (I) PML-RARA fusion gene detection using RT-PCR, followed by 2% agarose gel electrophoresis. The amplification of a 214 bp product identified PML-RARA long transcript. 1- 100 bp ladder; 2- Patient's sample; 3- Healthy donor negative control; 4- No amplification control (H2O); 5- Positive control (NB4 cell line) (J) FLT3-ITD was investigated by DNA PCR using fluorescent primers, followed by fragment analysis. Wild-type FLT3 gene amplification generated a product (peak) of 326 pb.
gr1.jpg
PMC9361310_01_gr1.jpg
fig0001
Abnormal promyelocytes were large, had bilobed nucleoli with basophilic cytoplasm, presented fine granules, and did not exhibit Auer rods, as shown in Fig. 1A. CD4+ cell count was 673/muL. Cytogenetic analysis of peripheral blood cells by G-banding showed 46,XY,t(15;17)(q22;q21)[10] (Fig. 1B). FISH analysis showed cells with one allele with the fusion involving the PML/RARA genes nuc ish (PML, RARA x2), (PML con RARA x1)[80]/ nic ish (PML,RARA)x2[20] (Fig. 1C). The immunophenotype was characterized by CD33, CD13, CD64, CD117, CD34, and CD15 positivity, while CD11b, CD16, HLA-DR, CD14, and CD7 were negative (Fig. 1D-H). FLT3 internal tandem duplications (ITD) were investigated by fragment analysis and were not found (Fig. 1I-J).
Pulmonary hyperleukocytosis finding and clinical evolution. (A) Chest radiograph showing bilateral interstitial and alveolar opacities; (B) Schematic diagram indicating the evolution of white blood cells (WBC) over time and treatment. ATRA- All-trans-retinoic acid; HU- Hydroxyurea; Ara-C- Cytarabine; Dauno- Daunorrubicin.
gr2.jpg
PMC9361310_01_gr2.jpg
fig0002
The patient evolved to dyspnea, hypoxemia, diffuse alveolar infiltrates, respiratory failure due to pulmonary leukostasis, and required orotracheal intubation three days after admission (Fig. 2A). Fig. 2B shows the clinical course.