International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - 10(1), January, 2018

Pages: 10-12

Date of Publication: 10-Jan-2018


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Secondary Ocular Involvement in Acute Myeloid Leukemia\? M0: A Rare Case Report

Author: Deepika Joshi, Ashok Kumar Bairwa, Sourav Shristi

Category: Healthcare

Abstract:We report a case of 45 year old female patient who presented with ocular pain and blurring of vision in both eyes (BCVA in right eye 0.1 logMAR and in left eye 0.1 logMAR). An ophthalmological evaluation revealed bilateral pale conjunctiva, vitreous degeneration, dilated and tortuous retinal vessels with multiple flame shaped and dot-blot haemorrhages, cotton wool spots and roth spots in both eyes. IOP in both eyes was 10 mm Hg. Haematological evaluation revealed the presence of Acute Myeloid Leukemia-M0 (undifferentiated) with Hb 3.2 gm%. General physical examination showed severe pallor. On examination bilateral
basal crepts and sternal tenderness found. Other causes of severe anaemia have been ruled out. This case documents the occurence of leukemic retinopathy in rare type of leukemia i.e Acute Myeloid Leukemia-M0 (3-5% of Acute Myeloid Leukemia).
Differential diagnosis: Thrombocytopenia, Severe anaemia, Hyperviscocity.

Keywords: Acute Myeloid Leukemia– M0, Roth spots, Basal crepts, Sternal tenderness, Leukemic retinopathy

DOI: 10.7324/IJCRR.2018.1013

Full Text:

Introduction

Acute Myeloid Leukemia is subdivided into M0 – M7 .  Acute Myeloid Leukemia- M0 is rare ( 3 – 5 % of Acute Myeloid Leukemia).3Ocular involvement in leukemia is classified as (1) Direct or primary leukemic infiltration (2) Indirect or secondary ocular involvement . The direct leukemic infiltration show three patterns: anterior segment uveal infiltration , orbital infiltration  and neuro-ophthalmic signs of C.N.S. The secondary changes are result of haematological abnormalities of leukemia such as anaemia, thrombocytopenia, hyperviscocity  . These can manifest as retinal or vitreous haemorrhage and vascular occlusions .1 The retina is involved more often than any other ocular tissue. It is estimated that 69 % of all patients with leukemia show fundus changes at some point of course of their disease.4

Case report

A 45 year old female patient referred to our ophthalmology department with complaint of ocular pain and blurring of  vision in both eyes . She also had shortness of breath and easy fatigability. There was no history of any systemic afflictions such as Diabetes mellitus , HTN , any vasculitis, blood dyscrasias, blood transfusion . On general examination patient was calm, cooperative and conscious. Severe pallor was present, afebrile,  P.R – 114/min , B.P – 130/90, R.R – 18/min . Systemic examination revealed bilateral basal crepitations and sternal tenderness.

On ophthalmological examination : Best corrected visual acuity was 0.1 logMAR (OD) and 0.1 logMAR  (OS) . Conjunctiva was pale . Slit lamp examination revealed bilateral vitreous degeneration. I.O.P was 10 mm Hg (OD) and 10 mm Hg (OS) by NCT. Dilated fundus examination showed clear media with normal sized optic disc. The vessels were dilated and tortuous with multiple flame shaped and dot blot haemorrhages in all four quadrants of eye . Multiple cotton wool spots and Roth spots were present in both eyes .                                                                     

In R.N.T Medical College all routine investigations were performed in which  Hb = 3.2gm/dl  ;  RBC = 1.14 m/cu mm; TLC  = 14,400( raised ) ;  DLC =  Lymphocytes = 58.5% ( High) , Granulocytes = 24 .6 % ( Low) ;  MCHC  = 30.70 (low)  ;  Reticulocyte count = 2.00 ; ESR = 49 ; SGOT =546 (raised)  ; SGPT (raised) ; HCV antibodies = NR ;  MP QBC = negative ; VDRL = NR ; HBsAg = negative. Peripheral blood smear  -  RBC – moderate anisopoikilocytosis, moderate hypochromic, pencil cells seen

                                                   WBC – 18000 cells / cu mm (Raised count)

  DLC – Blast cells: 50% (raised)

                                                                Lymphocytes: 10%

                                                                Polyneutrophils: 25 %

                                                                Band form: 7%

                                                                Myelocytes: 8%

      PLATELETS – adequate in number.

  HAEMOPARASITES – not seen

Based on these ophthalmological, systemic and haematological findings diagnosis of Acute Myeloid Leukemia– M0 with CHF was made.

TREATMENT RECEIVED : The patient received 2 units of blood transfusion(Packed Cell Volume) , Vit B 12 and folate supplements and Injection Furosemide 2 amp I.V stat in our hospital and after she was diagnosed with Acute Myeloid Leukemia– M0 patient was referred to Haemato – Oncologist for further management .   

Discussion

Leukemias are malignant neoplasms of haematopoetic stem cells, characterized by diffuse replacement of bone marrow by neoplastic cells . Ophthalmic involvement can be classified into two major categories (1)Primary or Direct leukemic infiltration (2.) Secondary or Indirect involvement. The direct leukemic infiltration show three patterns: anterior segment uveal infiltration, orbital infiltration and neuro-ophthalmic signs of C.N.S leukemia that include optic nerve infiltration, cranial nerve palsies and papilloedema. The secondary changes are the result of haematological abnormalities of leukemia such as anaemia, thrombocytopenia, hyperviscocity and immunosuppresion. These can manifest as Retinal or Vitreous haemorrhage, infections and as vascular occlusions. The ophthalmic manifestations of leukemia tend to involve more of posterior than anterior segment structures of eye and resulted more from secondary haematological complications rather than primary leukemic infiltration .1

In the era before effective antileukemic therapy, retinopathy was believed to be of no prognostic significance in acute leukemia. However recent reports have demonstrated that the presence of ocular involvement is associated with poor prognosis in acute childhood leukemias. Therefore it is important to consider an ophthalmic evaluation at the time of diagnosis of acute leukemia in adults and children2.

The acute leukemias are characterized by replacement of bone marrow with very immature cells called BLASTS. Under normal conditions, blasts forms constitute fewer than 5% of nucleated cells of bone marrow and are seen in peripheral blood except during periods of profound over-production of blood cells. Blast cells are primitive precursors lacking many of features of differentiation. Lymphoid blasts are differentiated from myeloid blasts on the basis of standard morphologic and cytochemical differences, based on these acute leukemias are subdivided . Within French – American – British (FAB) classification, ALL has been subdivided into three types : L1 , L2 , L3 , while subdivisions of Acute Myeloid Leukemia are called M0 – M7. Acute Myeloid Leukemia-M0 is rarest (3-5% of leukemias).3

The retina is involved in leukemia more often than any other ocular tissue. It is estimated that 69 % of all patients with leukemia show fundus changes at some point of course of their disease.4

The early manifestations (because of haematological disturbances) are venous dilation and tortousity .5

 Haemorrhages may occur in all levels of retina, usually in posterior pole and may extend into vitreous . They may be round or flame shaped and often has white component. The white area consists of leukemic cells and debris, platelet fibrin aggregates or septic emboli. A similar clinical picture can be seen in severe anaemia , thrombocytopenia and hyperviscocity.6

Cotton wool spots can be seen and are probably due to ischaemia from anaemia, hyperviscocity or leukemic infiltrate7

In this case patients complete systemic , ophthalmological and haematological examination clearly demonstrates Acute Myeloid Leukemia– M0kind of Acute Myeloid Leukemia(Acute Myeloid Leukemia) .

Conclusion:

This is rare case entity as very few cases of  ACUTE MYELOID LEUKEMIA– M0  are reported in literature . Although the ophthalmologist has a secondary role in treatment of leukemia , a prompt recognition of the ocular manifestations and their importance as a sign of possible extramedullary disease is crucial if appropriate therapy is to be initiated . We suggest that full collaboration among Physicians , Oncologists , Haematologists and Ophthalmologists is needed with prompt ophthalmic assessment of patients suspected to have eye manifestations .

References:

1 . Reddy SC, Menon BS. A prospective study of ocularmanifestations in childhood acute leukaemia. ActaOphthalmol Scand 1998; 76: 700–703

2. Ohkoshi K, Tsiaras WG. Prognostic importance ofophthalmic manifestations in childhood leukaemia. Br JOphthalmol 1992; 76: 651–655

3. Willman CL. Acute leukemias: a paradigm for the integration of new technologies in diagnosis andclassification. Mod Pathol 1999; 12: 218–228

4.Alemayehu W, Shamebo M, Bedri A, Mengistu Z. Ocular manifestations of leukaemia in Ethiopians. Ethiop Med J 1996; 34: 217–224

5.Ballantyne AJ, Michaelson IC. Textbook of the Fundus of theEye. Williams and Wilkins: Baltimore, 1970; 290–292

6.Allen RA, Straatsma BR. Ocular involvement in leukaemia and allied disorders. Arch Ophthalmol 1961; 66: 490–508

7. Sharma T, Grewal J, Gupta S, Murray PI. Ophthalmic manifestations of acute leukaemia: The ophthalmologist’s role. Eye 2004;18:66

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Dr. Pramod Kumar Manjhi joined Editor-in-Chief since July 2021 onwards

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Awards, Research and Publication incentive Schemes by IJCRR

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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

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A study by Muhas C. et al. entitled \"Study on Knowledge & Awareness About Pharmacovigilance Among Pharmacists in South India\" is awarded Best article for Vol 14 issue 22
A study by Saurabh Suvidha entitled \"A Case of Mucoid Degeneration of Uterine Fibroid with Hydrosalphinx and Ovarian Cyst\" is awarded Best article of Vol 14 issue 21
A study by Alice Alice entitled \"Strengthening of Human Milk Banking across South Asian Countries: A Next Step Forward\" is awarded Best article of Vol 14 issue 20
A study by Sathyanarayanan AR et al. entitled \"The on-task Attention of Individuals with Autism Spectrum Disorder-An Eye Tracker Study Using Auticare\" is awarded Best article of Vol 14 issue 19
A study by Gupta P. et al. entitled \"A Short Review on \"A Novel Approach in Fast Dissolving Film & their Evaluation Studies\" is awarded Best Article of Vol 14 issue 18.
A study by Shafaque M. et al. entitled \"A Case-Control Study Performed in Karachi on Inflammatory Markers by Ciprofloxacin and CoAmoxicillin in Patients with Chronic Suppurative Otitis Media\" is awarded Best Article of Vol 14 issue 17
A study by Ali Nawaz et al. entitled \"A Comparative Study of Tubeless versus Standard Percutaneous Nephrolithotomy (PCNL) \? A Randomized Controlled Study\" is awarded Best Article for Vol 14 issue 16.
A study by Singh R. et al. entitled \"A Prospective Study to Find the Association of Astigmatism in Patients of Vernal Keratoconjunctivitis (VKC) in a Tertiary Health Care Centre in India (Vindhya Region MP)\" is awarded Best Article for Vol 14 issue 15
A Study by Humaira Tahir et al. entitled "Comparison of First Analgesic Demand after Major Surgeries of Obstetrics and Gynecology between Pre-Emptive Versus Intra-Operative Groups by Using Intravenous Paracetamol: A Cross-Sectional Study" is awarded Best Article for Vol 14 issue 14
A Study by Monica K. entitled "Risk Predictors for Lymphoma Development in Sjogren Syndrome - A Systematic Review" is awarded Best Article for Vol 14 issue 13
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A Study by Bhat Asifa et al. entitled "Efficacy of Modified Carbapenem Inactivation Method for Carbapenemase Detection and Comparative Evaluation with Polymerase Chain Reaction for the Identification of Carbapenemase Producing Klebsiella pneumonia Isolates" is awarded Best Article for Vol 13 issue 17
A Study by Gupta R. et al. entitled "A Clinical Study of Paediatric Tracheostomy: Our Experience in a Tertiary Care Hospital in North India" is awarded Best Article for Vol 13 issue 16
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A Study by Kumar S. et al. entitled "A Study on Clinical Spectrum, Laboratory Profile, Complications and Outcome of Pediatric Scrub Typhus Patients Admitted to an Intensive Care Unit from a Tertiary Care Hospital from Eastern India" is awarded Best Article for Vol 13 issue 09
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A Study by Sarmila G. B. et al. entitled "Study to Compare the Efficacy of Orally Administered Melatonin and Clonidine for Attenuation of Hemodynamic Response During Laryngoscopy and Endotracheal Intubation in Gastrointestinal Surgeries" is awarded Best Article for Vol 13 issue 07
A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06
A Study by Chen YY and Ghazali SRB entitled "Lifetime Trauma, posttraumatic stress disorder Symptoms and Early Adolescence Risk Factors for Poor Physical Health Outcome Among Malaysian Adolescents" is awarded Best Article of Vol 13 issue 04 Special issue on Current Updates in Plant Biology to Medicine to Healthcare Awareness in Malaysia
A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
A Study by Tarek Elwakil et al. entitled "Led Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model" is awarded Best Article of Vol 13 issue 02
A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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