Contributed by Martha Romero1, Carlos Saavedra1, Myriam Rodríguez2, Andrés F. Henao-Martínez3
1Department of Pathology and 2Hematology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia. 3Division of Infectious Diseases, University of Colorado Denver, USA.
An 83-year old man with a past medical history significant for meningioma and chronic myelomonocytic leukemia was admitted with fever, speech difficulties, and bruises. Laboratory data showed hyperleukocytosis and his urine culture was positive for Enterococcus faecalis. The patient received antibiotics with partial improvement. On hospital day 3, the patient developed dysarthria and severe right-sided weakness. A CT identified a left frontal meningioma (Figure 1a), surrounded by a subdural collection (Figure 1b). Gadolinium contrast MRI revealed a marked uniform enhancement in the left frontal region (Figure 1c). The collection was evacuated. Cultures collected showed no growth. On postoperative day 2, a CT showed new hyperintense lesions in the temporal and parietal regions. The family did not allow more invasive interventions. The patient passed peacefully on hospital day 8.
By H&E, the tissues showed three distinct areas of pathology (Figure 1d). The first composed by blood and fibrin (Figure 1e). The second constituted by tumor cells with oval nuclei without atypia, with round calcified bodies (Fig 1f white-arrows) and cellular whorls (Figure 1g), positive for PGR, EMA with 1% of proliferation and negative for MPO and CD68 (Figures 1i, 1j, 1k and 1l surrounded by broken black lines). The third lesion showed sheets of large blastic cells (Figure 1h), negative for PGR, with 80% of proliferation, positive for MPO, CD68 (Figures 1i, 1j, 1k and 1l), CD34 and CD117. Flow Cytometry did not detect CD45 negative cells (Figure 1m, broken lines), but identified 1.8% of cells positive for CD34 (Figure 1n, orange population) and 1.1% of monocytes (Figure 1o, red population). The blood smear showed monocytosis, with promonocytes and monoblasts (Figure 1p white and black arrows respectively). What are your diagnoses?