Mr. X, 99 years old
A 99-year-old patient was admitted to the hospital for complaints of decrease in response and blood in urine.
Patient is a known case of benign prostatic hyperplasia/ subdural hepatoma-s/p evacuation.
On admission, Mr. X was drowsy .Vital signs were unremarkable. Neurological examination revealed E4V2M3. Other systemic examinations were normal.
He was started on hydroxyurea after consultation with Hematologist. Repeat blood investigations showed wbc in decreasing trend.
However, the patient’s condition deteriorated, leading to the initiation of high-flow nasal cannula and noradrenaline due to septic shock, and he was subsequently declared deceased.
Chronic myeloid leukemia (CML) represents roughly 14% of all leukemias and primarily affects adults between 40 and 60 years old. It is driven by the Philadelphia chromosome, resulting from a balanced reciprocal translocation between chromosomes 9 and 22. This genetic alteration generates the BCR-ABL1 chimeric oncogene , which encodes a tyrosine kinase protein with a molecular weight of 210 kDa that leads to unchecked cell proliferation and impaired apoptosis. The BCR-ABL1 oncoproteins is expressed in various hematopoietic cells (myeloid, erythroid, megakaryocytes, and monocytes; less often mature B lymphocytes; rarely mature T lymphocytes )but not in other body cells.
Common symptoms, when they occur, typically involve signs of anemia and splenomegaly. These may include fatigue, malaise, weight loss (with a high leukemia burden), or early satiety, left upper quadrant pain, or masses due to splenomegaly. Less common symptoms can result from thrombotic or hyperviscosity-related complications due to severe leukocytosis or thrombocytosis, such as priapism, cardiovascular issues, myocardial infarction, venous thrombosis, visual disturbances, dyspnea, pulmonary insufficiency, drowsiness, loss of coordination, confusion, or cerebrovascular accidents.
CML typically progresses through an indolent chronic phase, followed by an accelerated phase, and eventually a terminal blastic phase. The blast crisis is marked by increased blast cells in the bone marrow or blood and leukemic infiltrates in soft tissues or skin. Unlike acute leukemias, which can quickly reverse or become fatal, CML has a slower progression. Without initial cure, it may lead to acute leukemia (75% myeloid, 25% lymphoid) or myelofibrosis, with a median survival of 3–4 years.
Diagnostic investigations involve blood counts, bone marrow aspirates, and cytogenetic analysis. Typical findings include leukocytosis commonly ranging from 10–500 × 10^9/L. The peripheral blood differential typically shows a left shift in hematopoiesis with a predominance of neutrophils and the presence of bands, myelocytes, metamyelocytes, promyelocytes, and blasts (usually ≤5%). Increased basophils and/or eosinophils are also frequent. While thrombocytosis is common, thrombocytopenia is rare and, if present, may indicate a worse prognosis or disease acceleration. Biochemical abnormalities include low leukocyte alkaline phosphatase levels and elevated vitamin B12, uric acid, lactic dehydrogenase, and lysozyme. The bone marrow typically shows hypercellularity with significant myeloid hyperplasia and a myeloid-to-erythroid ratio of 15–20:1. Marrow blasts are usually 5% or less; higher levels indicate a worse prognosis or possible transformation to an accelerated phase if ≥15%.
Peripheral smear of a CML patient
1- Blast cell (probably basophilic normoblast)
2- Band cell
3- Band cells going to be segmented
4- Dysplastic cell
5- Metamyelocyte
6- Basophil
7- Eosinophilic myelocyte
8- Latemeta myelocyte
Diagnostic confirmation of CML typically involves detecting the BCR-ABL1 fusion gene. In some cases, this may not be apparent with standard karyotyping but can be identified using fluorescence in situ hybridization (FISH) or polymerase chain reaction (PCR). Somatic mutations may help to diagnose but are not specifically pathognomonic of the disease, with the most detected including ASXL1, SETBP1, NRAS, KRAS, SRSF2, and TET2 and with low-frequency CBL, CSF3R, JAK2, and ETNKT. Some patients may have atypical features and other related disorders, such as atypical CML or chronic myelomonocytic leukemia, which generally have a poorer prognosis and do not respond to tyrosine kinase inhibitors (TKIs) as effectively.
metamyelocytes) comprising ≥10% of leukocytes
Frontline treatments for CML include imatinib, dasatinib, bosutinib, and nilotinib. Imatinib has demonstrated favorable long-term outcomes, with high rates of cytogenetic and molecular remission and a 10-year survival rate of approximately 85%. However, resistance to imatinib can occur, and second-generation TKIs may be required. For advanced or refractory cases, allogeneic stem cell transplantation remains a viable option, offering a potential cure for about 70% of patients in chronic phase.
https://imagebank.hematology.org/image/61888 /chronic-myeloid-leukemia-presentation-in-peripheral-blood-1
Dr. Madhumitha R M DNB General Medicine Resident Kauvery Hospital, Chennai
Dr. Sivaram Kannan Clinical Lead & Chief Consultant Physician Kauvery Hospital, Chennai
Dr. Arshad Raja Associate Consultant – Haematology and Haemato Oncology Kauvery Hospital, Chennai
