A 60 year old previously healthy female presented for evaluation of a painful sacral decubitus ulcer. In the initial workup, CBC showed leukocytosis of 51 with a monocytic differentiation and 55% blasts, macrocytic anemia of 4.6 Hgb, and thrombocytopenia of 32. She denied any classic B-type symptoms, but did have four days of fatigue and chronic night sweats, previously attributed to menopause. She had no evidence of bleeding, and was transfused appropriately, but had ongoing severe thrombocytopenia. Oncology was consulted and bone marrow biopsy confirmed the diagnosis of acute myeloid leukemia with monocytic differentiation. After initiation of antibiotic therapy for her sacral wound, she was started on 7+3 chemotherapy. During treatment, she suffered from pancytopenia, and interestingly developed fever and chills with platelet transfusion. She was attempted to be treated with IVIG for concern of post transfusion purpura, but again had fevers and chills. She ultimately stabilized with HLA-matched platelets. The remainder of her course was notable for diarrhea and bloody stools, febrile neutropenia and bacteremia. Ultimately, she was no longer transfusion dependent and repeat bone marrow biopsy showed remission with blasts down to 1%, allowing the patient to be assessed for a bone marrow transplant. There are several important tenants underlined in this case. First, the importance of consideration for factors contributing to poor wound healing, as well as the importance of obtaining a differential to accompany a marked CBC abnormality. From a Hematologic perspective, this case describes AML with monocytic differentiation, as well as complications such as febrile neutropenia, pancytopenia and concern for the underrecognized post-transfusion purpura. In total, this case highlights the need for multidisciplinary care of such medically complex patients.
Zimmer M, Alakhras H, Misra D, Aguinaga S. AML: a real pain in the sacrum. Paper presented at: The American College of Physicians Michigan Chapter Residents Day / Medical Students Day; 2022 May 13; Dearborn, MI.