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CASE SNIPPETS
Year : 2009  |  Volume : 55  |  Issue : 3  |  Page : 197

Auer rod-like inclusions in reactive plasmacytosis seen with acute myeloid leukemia


Department of Pathology, Lady Hardinge Medical College & Associated Hospitals, New Delhi, India

Date of Web Publication2-Nov-2009

Correspondence Address:
M Pujani
Department of Pathology, Lady Hardinge Medical College & Associated Hospitals, New Delhi
India
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DOI: 10.4103/0022-3859.57403

PMID: 19884747

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How to cite this article:
Sharma S, Malhan P, Pujani M, Pujani M. Auer rod-like inclusions in reactive plasmacytosis seen with acute myeloid leukemia. J Postgrad Med 2009;55:197

How to cite this URL:
Sharma S, Malhan P, Pujani M, Pujani M. Auer rod-like inclusions in reactive plasmacytosis seen with acute myeloid leukemia. J Postgrad Med [serial online] 2009 [cited 2014 Jul 23];55:197. Available from: http://www.jpgmonline.com/text.asp?2009/55/3/197/57403


Plasmacytosis occurs in 6-7% of patients with acute myeloid leukemia (AML). [1] This should be treated with caution because of the rare coexistence of multiple myeloma with AML. [2] We report a rare case of reactive plasmacytosis occurring in therapy-related AML (t-AML) with Auer rod-like inclusions (ARLI) in plasma cells. A 65-year-old male presented with complaints of fever and breathlessness for two weeks. He had received six cycles of chemotherapy (Methotrexate, Vinblastine, Cisplatin, Doxorubicin) about a year back for transitional cell carcinoma. Laboratory investigations showed pancytopenia with hemoglobin concentration of 6 g/dl, total leucocyte count (TLC) 1,100/ul and platelet count 7000/ul. Peripheral smear revealed 4% blasts while bone marrow aspirate showed presence of 52% myeloblasts [Figure 1] with strong positivity for myeloperoxidase (MPO) and Sudan Black B (SBB) and negativity for nonspecific esterase (NSE). There was plasmacytosis (16% of all nucleated cells) with few bi/multinucleate forms. Some of these plasma cells showed presence of MPO-negative ARLI [Figure 1]. Serum protein electophoresis (SPE) revealed polyclonal increase in globulins without any M spike. A final diagnosis of therapy-related acute myeloid leukemia (t-AML) with reactive plasmacytosis was given. Further investigations such as bone marrow biopsy, immunophenotyping and urine examination could not be performed as the patient expired the very next day. Secondary leukemias or therapy-related myeloid neoplasms can be divided into two distinct subsets. The most common occur 5-10 years after exposure to alkylating agents and/or ionizing radiation. The second category of t-AML/therapy related-Myelodysplastic Syndrome encompasses 20-30% of patients that follow treatment with Topoisomerase II inhibitors and has a latency period of one to five years, as in our case. The association of AML with plasmacytosis is well known with several case reports in the literature. [1],[3] Rosenthal et al., observed reactive plasmacytosis in approximately 7% of all patients with AML and the number of plasma cells ranged from 5-13%. [1] The possible pathogenetic mechanism could be that high production of IL-6 by leukemic blast cells causes paracrine growth stimulation of plasma cells resulting in marrow plasmacytosis. [3]

ARLI have been detected in patients with multiple myeloma. [4],[5] Most of these cases had IgA Kappa multiple myeloma or IgG multiple myeloma. [4],[5] The exact origin of these inclusions is not known, although cytochemical stains point towards a link with lysosomes of plasma cells showing acid phosphatase, β-glucoronidase positivity and/or a-naphthyl acetate esterase (ANAE) positivity. These inclusions do not influence prognosis in patients with multiple myeloma but are of morphological variance. [4] We found only an occasional case report describing ARLI in reactive plasma cells. Petr reported a case of ARLI in reactive plasma cells in a patient of aplastic anemia. [6] The index case also shows prominent Auer rod-like intra-cytoplasmic inclusions in reactive plasmacytosis in a case of t-AML. The index case is unique as there is presence of Auer rod-like intracytoplasmic inclusions in reactive plasmacytosis in a case of t-AML, which has not been reported earlier.

 
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1.Rosenthal NS, Farhi DC. Reactive plasmacytosis and lymphocytosis in acute myeloid leukemia. Hematol Pathol 1994;8:43-51.  Back to cited text no. 1  [PUBMED]    
2.Shukla J, Patne SCU, Singh NK, Usha. Simultaneous appearance of Dual malignancies of hematopoietic system-multiple myeloma and acute myeloid leukemia.Indian J Pathol Microbiol 2008;51:118-20.  Back to cited text no. 2  [PUBMED]  Medknow Journal  
3.Wulf GG, Jahns Streubel G, Hemmerlein B, Bonnekessen K, Wormann B, Hiddemann W. Plasmacytosis in acute myeloid leukemia: Two cases of plasmacytosis and increased IL-6 production in the AML blast cells. Ann Hematol 1998;76:273-7.  Back to cited text no. 3      
4.Mahesha V, Munita MB, Varma N, Sakhuja V. Auer Rod - like inclusions in immunoglobulin A Multiple Myeloma. Arch Pathol Lab Med 2005;129:706-7.  Back to cited text no. 4      
5.Hutter G, Nowak D, Blau IW, Thiel E. Auer rod like intracytoplasmic inclusions in multiple myeloma- A case report and review of literature. Int J Lab Hematol 2009;31:236-40.  Back to cited text no. 5      
6.Lemez P. Auer rod-like inclusions in cells of B-Lymphocytic Lineage. Acta Haematol 1988; 80:177-8.  Back to cited text no. 6  [PUBMED]    


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2004 - Journal of Postgraduate Medicine
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