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Autor*: A. Buliková, J. Kissová
Description:
42 years old man comes to hospital with 2 weeks long history of fever and 1 weeks history of bleeding symptoms. Laboratory evaluation shows marked leukocytosis (95G/l), mild anaemia (121 g/l) and moderate thrombocytopenia (45G/l) in CBC and coagulopathy. Peripheral blood smears show hypogranular or agranular pathological promyelocytes, but some Auer rods occur. Similar picture show bone marrow smears but some cells contain bundles of Auer rods or occasionally even faggot cells is find. Strong positivity of myeloperoxidase staining supports diagnose of promyelocytic leukaemia (not confirmed by cytogenetic or molecular genetic evaluation in case of patient's really short survivor).
Zařazení*:
Acute promyelocytic leukaemia (AML with t(15;17)(q22;q12), (PML/RAR alfa) and variants)
Přílohy*:
Description: The main feature of this type acute myeloblastic leukaemia is bi-lobed nuclear shape and presence of dust-like reddish granules in cytoplasm. Some tumour cells can be even agranular. Leukocytosis is usual when one compares this type with classic hyper-granular form. 
Description: Some pathological promyelocytes are completely agranular (lower left) with kidney shaped nucleus. Some Auer rods even in bundles can be find almost in every cases - in this one there are 3-4 thick Auer rods in the second cell from bellow at right. 
Description: Tumour cell with bi-lobar nucleus, clear nucleoli in every nuclear part, some (upper left) or no (lower right) cytoplasmic granulation. 
Description: Bi-lobar nucleus and clear Auer rod but in almost agranular cytoplasm are typical features in the cell at upper left. Two large lobes of nucleus joined by a narrow bridge (cell at the 3 o'clock) present another characteristics of the variant form PML. 
Description: Numerous bi-lobar or kidney shaped nuclei and agranular or fine granular cytoplasm in "promyelocytes" in peripheral blood smears in patient with AML M3v. Cytoplasm of some cells (example at upper left) can contain more pronounced usually isolated red inclusion. 
Description: Bi-lobular or multilobular (cell at the middle right) nuclei and fine reddish granulation in cytoplasm are also typical in tumour cells in bone marrow. 
Description: In all cases of acute leukaemia with bilobar nuclei it is really necessary carefully search for cells with bundles Auer rods in cytoplasm ("faggot cells"). This finding brings high suspicion to diagnose of microgranular variant of APL, which should be confirmed by cytogenetic and/or molecular genetic examination - presence of
t(15;17) and/or PML/RARalfa fusion gene. 
Description: Bi-lobar or irregular nuclear shape in variant PML. There is one faggot cell at the upper left. Some tumour cells in variant APL can have cytoplasmic protrusions (four from five cells in lower part of the picture)- 
Description: Four tumour cells in variant APL with bi-lobar nuclei, rather fine cytoplasmic granulation and cytoplasmic projections at the outline of the cell. There is one typical hypergranular promyelocyte at the upper left with cytoplasm filed by large numerous azurophilic granules, which totally obscure the nuclear cytoplasmic margin. 
Description: Myeloperoxidase reaction is strongly positive in contrast with "monocyte appearance" of some tumour cells in variant APL (in monocytes is usually weak or almost negative MPOX reaction). This finding can support suspicion to granulocytic origin of leukemic cells.