Blood Res 2021; 56(2): 60-60  https://doi.org/10.5045/br.2021.2021004
Hemorrhagic stroke due to leukostasis in pediatric mixed-phenotype acute leukemia
Shunsuke Yamamoto1, Yuhki Koga1, Kenichi Tetsuhara1,2, Noriyuki Kaku1,2, Hiroaki Ono1, Satoshi O. Suzuki3, Toru Iwaki3, Shouichi Ohga1
1Department of Pediatrics, Graduate School of Medical Sciences, 2Emergency and Critical Care Center, Kyushu University, 3Department of Neuropathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
Correspondence to: Yuhki Koga, M.D., Ph.D., Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka 812-8582, Japan, E-mail: yuuki-k@pediatr.med.kyushu-u.ac.jp
Received: January 9, 2021; Revised: February 23, 2021; Accepted: April 5, 2021; Published online: May 14, 2021.
© The Korean Journal of Hematology. All rights reserved.

cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Body

A 13-year-old Japanese boy presented to our emergency room with disturbed consciousness following a 3-day history of fever and headache. He presented with hyperleukocytosis (white cell count, 480×109/L; 82.4% blasts), anemia (hemoglobin concentration, 4.4 g/dL), thrombocytopenia (64×109/L), and impending tumor lysis syndrome with consumptive coagulopathy. Head computed tomography (CT) showed multiple intracranial hemorrhages involving the brainstem (A, white arrows). Thus, a diagnosis of mixed-phenotype acute leukemia with T-lymphoid and myeloid lineage markers was made within 12 hours after admission, and chemotherapy was immediately initiated. Despite intensive therapy, he died on day 4 after admission because of multiple hemorrhages and intracranial hypertension. With written informed consent from the patient’s parents, a postmortem examination of the brain was performed. Histopathological study showed multiple hemorrhages, numerous large leukemic blasts in the microvessel lumens, and cerebral tissue ischemic changes (B, C, white arrows, hematoxylin and eosin staining); however, there was no evidence of monosomy 7 or minor bcr-abl fusion. These findings indicated that the rapidly proliferating blasts in leukostasis led to hyperviscosity, cerebral infarction, and subsequent hemorrhage accompanied by coagulopathy. Therefore, hemorrhagic stroke with hyperleukocytosis in teenagers is an initial presentation of aggressive leukemia.



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