Diagnostic Challenges in Acute Leukemia: A Case Report of Inconclusive Bone Marrow with Blasts in Peripheral Smear
Case Report
DOI:
https://doi.org/10.55175/cdk.v53i06.1939Keywords:
Acute leukemia, blast cells, bone marrow evaluation, case report, peripheral blood smear, thrombocytopeniaAbstract
Introduction: Acute leukemia is a hematologic malignancy characterized by the proliferation of immature leukocytes that disrupt normal hematopoiesis, leading to cytopenias and systemic symptoms. Diagnosis typically relies on bone marrow evaluation. Peripheral blood findings may be critical when marrow results are inconclusive. Case: A 23-year-old male with melena, severe anemia, generalized weakness, and a two-week history of back pain. Physical examination revealed pallor and splenomegaly. Initial laboratory findings showed severe macrocytic anemia, leukocytosis, and thrombocytopenia. A peripheral blood smear revealed 63% blasts with a high nuclear-to-cytoplasmic ratio and prominent nucleoli. Despite these findings, the diagnosis of acute leukemia, bone marrow aspiration was inconclusive. Elevated lactate dehydrogenase indicated a high tumor burden. Discussion: Peripheral smear evaluation, supported by cytogenetic and flow cytometry studies, is vital for early diagnosis. Acute leukemia must remain a differential consideration even in the absence of definitive bone marrow findings. Conclusion: This case highlights the diagnostic challenge of acute leukemia with inconclusive initial bone marrow findings. Peripheral blood smear detection of circulating blasts was crucial in establishing the diagnosis. Early recognition through integrated diagnostic evaluation remains essential for the timely initiation of treatment.
Downloads
References
Dohner H, Weisdorf DJ, Bloomfield CD. Acute myeloid leukemia. N Engl J Med. 2015;373(12):1136–52. doi: 10.1056/NEJMra1406184.
Lichtman MA. Acute myelogenous leukemia: clinical presentation and diagnosis. Hematology Am Soc Hematol Educ Program.2013;2013(1):38–45. doi: 10.1182/asheducation-2013.1.38.
Sun Y, Wang Y, Zhang W, Hao C, Teng G, Liu Y, et al. Genomic and epigenomic alterations in leukemia: a new era of targeted therapy. Front Med. 2018;12(4):421–38. doi: 10.1007/s11684-018-0646-1.
Hanoun M, Zhang D, Mizoguchi T, Pinho S, Lepore H, Purton LE, et al. Acute myeloid leukemia induces remodeling of the vascular niche to impair normal hematopoiesis. Nat Cell Biol. 2014;16(6):675–86. doi: 10.1038/ncb2987.
Tallman MS, Gilliland DG, Rowe JM. Drug therapy for acute myeloid leukemia. Blood. 2005;106(4):1154–63. doi: 10.1182/blood-2005-03-1031.
Arber DA, Orazi A, Hasserjian R, Thiele J, Borowitz MJ, Le Beau MM, et al. The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia. Blood. 2016;127(20):2391–405. doi: 10.1182/blood-2016-03-643544.
Varela A, Torres R, Sangro B. Dry tap in bone marrow aspiration: causes and diagnostic approaches. Clin Lymphoma Myeloma Leuk. 2015;15(7):e127–30. doi: 10.1016/j.clml.2015.03.003.
Bain BJ. Bone marrow biopsy morbidity and mortality. Br J Haematol. 2003;121(6):949–51. doi: 10.1046/j.1365-2141.2003.04329.x.
Ruby CE, Pavletic SZ. Unexplained cytopenias as the initial presentation of hematologic malignancy. Hematol Oncol Clin North Am.2023;37(1):1–15. doi: 10.1016/j.hoc.2022.09.001.
Tallman MS, Altman JK. How I treat acute promyelocytic leukemia. Blood. 2009;114(25):5126–35. doi: 10.1182/blood-2009-07-216457.
Riley RS, Hogan TF, Pavot DR, Forsythe R, Massey D, Smith E, et al. A pathologist's perspective on bone marrow aspiration and biopsy: I. Performing a bone marrow examination. J Clin Lab Anal. 2004;18(2):70–90. doi: 10.1002/jcla.20008.
Porwit A. Clinical flow cytometry. In: Greer JP, Arber DA, Glader B, List AF, Means RT Jr, Paraskevas F, et al., editors. Wintrobe's clinical hematology. 14th ed. Philadelphia (PA): Wolters Kluwer; 2019. p. 232–303.
Bain BJ. Bone marrow biopsy morbidity and mortality. Br J Haematol. 2003;121(6):949–51. doi: 10.1046/j.1365-2141.2003.04329.x.
Borowitz MJ, Chan JK. Acute leukemia: principles of immunophenotyping. Arch Pathol Lab Med. 1998;122(12):1005–11.
Arber DA, Orazi A, Hasserjian R, Thiele J, Borowitz MJ, Le Beau MM, et al. The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia. Blood. 2016;127(20):2391–405. doi: 10.1182/blood-2016-03-643544.
Andres E, Serraj K. Optimal management of pernicious anemia. J Blood Med. 2012;3:97–103. doi: 10.2147/JBM.S25620.
Bashawri LA. Bone marrow examination: indications and diagnostic value. Saudi Med J. 2002;23(2):191–6.
Dogan A, Demircioglu S. Diagnostic importance of bone marrow aspiration evaluation: a single-center study. Pak J Med Sci. 2022;38(4):811–5. doi: 10.12669/pjms.38.4.4797.
Calvet L, Pereira B, Sapin AF, Mareynat G, Lautrette A, Souweine B. Contribution to diagnosis and treatment of bone marrow aspirate results in critically ill patients undergoing bone marrow aspiration: a retrospective study of 193 consecutive patients. J Intensive Care. 2017;5(1):67. doi: 10.1186/s40560-017-0263-7.
Takeda Y, Hara T, Hayashi M, Fukuyama R, Onozawa M, Hino M, et al. Bone marrow necrosis in a patient with B-cell precursor acute lymphoblastic leukemia. Intern Med. 2017;56(13):1693–6. doi: 10.2169/internalmedicine.56.8132.
Bhatia P, Raina S, Kaul D, Gupta A. Bone marrow necrosis in a child with precursor T-cell acute lymphoblastic leukemia. Indian J Hematol Blood Transfus. 2012;28(2):125–7. doi: 10.1007/s12288-011-0101-1.
Wu W, Yang M, Jiang Y, Wang Y, Liu Y, Zhang X, et al. Asymmetrical bone marrow involvement in relapse after allogeneic stem cell transplantation. J Int Med Res. 2021;49(2):1–7. doi: 10.1177/0300060521990950.
Cryer B, Feldman M. Cyclooxygenase-1 and cyclooxygenase-2 selectivity of widely used nonsteroidal anti-inflammatory drugs. Am J Med. 1998;104(5):413–21. doi: 10.1016/S0002-9343(98)00091-6.
Bain BJ. The peripheral blood smear. Clin Lab Med. 2002;22(1):89–110. doi: 10.1016/S0272-2712(03)00006-1.
Tashiro H, Ichikawa M, Yoshimoto G, Miyamoto T, Akashi K, Kato K, et al. Acute leukemia with non-diagnostic bone marrow aspiration: importance of peripheral smear and flow cytometry. Int J Hematol. 2022;116(3):407–12. doi: 10.1007/s12185-022-03292-0.
Soylu R, Buyukasik Y, Cetiner D, Buyukasik NS, Koca E, Haznedaroglu IC, et al. Overt gastrointestinal bleeding in haematologic neoplasms. Dig Liver Dis. 2005;37(12):917–22. doi: 10.1016/j.dld.2005.05.011.
Avvisati G, Tirindelli MC, Annibali O. Thrombocytopenia and haemorrhagic risk in cancer patients. Crit Rev Oncol Hematol. 2003;48(1):13–6. doi: 10.1016/j.critrevonc.2003.04.001.
Ruby A, Shreedhara K, Dinesh S. Aleukemic leukemia: a rare presentation. RGUHS J Med Sci. 2023;13(4):205–7.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Putu Itta Sandi Lesmana Dewi, Tjokorda Gede Dharmayudha
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
