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Figure 1. A 29-year-old female presented with 2 weeks history of spontaneous bruising and 4 days history of headache and blurred vision. Clinical examination revealed visual field defect and bilateral retinal hemorrhages. CT head (top left) showed R occipital lobe bleed and shift in the midline to the left. Full blood count showed anemia and throbcocytopenia. WBC was 9 x 109/L. clotting screen showed PT 16.4 sec, APTT 26.8 sec and Fibrinogen of 0.6 g/L. Blood film (1) showed hypergranular blasts with bilobed nuclei. In view of the intracerebral bleed, we opted to treat the patients with ATO (Arsenic Trioxide) and ATRA instead of chemotherapy to avoid the prolonged subsequent cytopenia. The blood film from Day 8 (2) showed some maturation into myelocyte and band forms. Day 19 blood film (3) showed further maturation to neutrophils with hypogranular cytoplasm and dysplastic morphology. The patient platelets count was > 100 x 10/L day 26 of treatment. The platelets count completely recovered on day 28 and the blood film (4) started to show normal looking neutrophils. The patient never became significantly neutropenic during the treatment. In this case, both ATRA- and ATO-induced terminal differentiation of the abnormal promyelocytes. This has shown a good and possibly accelerated differentiation with ATRA combined with ATO without undue cytopenia.
This figure shows blood film morphology in APML patient on ATO+ATRA induction treatment day 0 showing hypergranular blasts with bilobed nuclei.
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