CASE 2:
A15 year old student living in Kahuta, Punjab, presented with:
C/O: Fever …….. 7 days.
The fever was high grade (104 F), accompanied by rigors and chills, and associated with productive cough for 3 days and black coloured stools.
Family history was not significant for any relevant disease. Consanguinity was reported. The patient took some antipyretics. There was no history of blood transfusion.
He was pale, without any jaundice and organomegaly. Skin was normal.
Laboratory reports showed TLC 500/uL, Hb 10 g/dL, MCV 58 fL, MCH 27 pg, Platelets 140000/uL, and ESR 19mm in 1st hr.
Samples for peripheral blood morphology, MP test, Hepatitis serology and stool for occult blood were sent.
Peripheral morphology revealed anisocytosis, microcytosis, hypochromia, macrocytosis, and occasional blast cells seen. MP was not seen on peripheral morphology. Serology for Hepatitis B and C was negative. Stool was positive for occult blood.
A bone marrow examination was requested, which revealed difficult aspiration, a diluted marrow, suppression of myelopoiesis and erythropoiesis; megakaryocytes were present, with normal plasma cells; 60% of all nucleated cells were blasts having high N:C ratio and 0-1 inconspuicous nucleoli, and frequency of nuclear clefting was prominent . Special stains showed negativity for SBB & PAS, and focal weak positivity for ACP. An opinion of Aleukemic or Sub leukemic Acute Lymphoblastic Leukemia was made.