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Case study (26) – Acute myeloid leukemia

Case study (26) – Acute myeloid leukemia

A 36-year-old female presented with a short history of increasing tiredness and bruising.

Laboratory Investigation:

1. CBC:

Hemoglobin (Hb) 79 g/L

White blood cells (WBC) 34.8 X 109/L

Platelets 21 X 109/L

2. Bone marrow aspiration:

A bone marrow aspirate was taken.

Six weeks later, she developed a febrile illness with facial swelling and orbital edema.

She also became short of breath and hypotensive and had a single episode of hemoptysis. A chest x-ray was performed.


Q1. What is the presentation diagnosis?

Q2. What is the likeliest cause of her febrile illness?

Q3. How should she be treated?


A1. The bone marrow aspirate is infiltrated by primitive leukemic cells which have Auer rods. The diagnosis is therefore acute myeloid leukemia.

A2. Infection is clearly the likeliest cause in this setting. The marked facial cellulitis would be compatible with a Gram-positive skin infection but an x-ray of her sinuses should also be carried out. 

The chest x-ray shows consolidation. Cavitation should be carefully looked for, and, if present, would support a diagnosis of staphylococcal pneumonia.

The CT scan confirms cavitation, but the nature of these peripheral, triangular, and enhancing lesions is highly suggestive of fungal pneumonia.

A3. Every attempt must be made to make a microbiological diagnosis (blood cultures, a culture of aspirate from the skin, sputum culture, possibly bronchoalveolar lavage). 

She should receive broad-spectrum antibiotic and antifungal therapy, and this should include systemic liposomal amphotericin or some other lipid formulation of amphotericin B. 

Oral itraconazole is used as prophylaxis and intravenous itraconazole is active in the treatment of aspergillosis. 

Caspofungin is a newer anti-fungal agent active in both candidiasis and aspergillosis. 

Voriconazole has a broader spectrum of activity; posaconazole has recently become available for prophylaxis and treatment for invasive fungal infections in immunocompromised individuals.

The development of hemoptysis is disturbing, as there is a high risk of massive pulmonary hemorrhage in thrombocytopenic patients with invasive pulmonary fungal infections, and surgical resection should be considered for solitary lesions – this is probably inappropriate in this patient, who has multiple lesions.