Case 87 -- Acute Leukemia, Nodular Skin Lesions and Splenomegaly

Contributed by Karen K. Deal, MD, PhD, N. Paul Ohori, MD, and A. William Pasculle, ScD
Published on line in December 1996


PATIENT HISTORY AND HOSPITAL COURSE:

This 22-year old man was diagnosed with acute lymphoblastic leukemia (see image 01 and image 02) of B-cell lineage one month after sustaining a rib injury while wrestling. In the weeks prior to diagnosis, his rib injury healed, but he experienced upper respiratory symptoms, together with fevers, anorexia, and lightheadedness. A Monospot test was positive. He responded well to induction chemotherapy, and he was discharged on a regimen of vincristine and L-asparaginase. On day 14 of chemotherapy, he developed rigors and fevers to 104 degrees F. He was rehospitalized and noted to have numerous discrete non-blanching, erythematous papular and vesicular lesions over his trunk and upper and lower extremities. He had a lower lip "cold sore" and a crusted lesion within the left nare. The spleen was palpable 4 cm below the costal margin. Chorioretinitis was present. Fever persisted despite aggressive, broad-spectrum antibiotics. His hospital course included: skin biopsy (see image 03, image 04 and images 05), cultures (see image 06), and splenectomy with liver wedge biopsy (see gross and microscopic descriptions below). Systemic therapy included liposomal amphotericin B and intravenous fluconazole, as well as intraocular antifungal therapy. The patient remained in remission of his leukemia during hospitalization and was discharged one month after admission on oral fluconazole and metranidazole.


GROSS DESCRIPTION

MICROSCOPIC DESCRIPTION

MOLECULAR AND IMMUNOHISTOLOGIC STUDIES

FINAL DIAGNOSIS

THERAPY


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