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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 25-28

The double jeopardy of leukemia and dengue: A report of three cases


Department of Pathology, Father Muller Medical College, Mangalore, Karnataka, India

Date of Submission21-Oct-2019
Date of Acceptance18-Nov-2019
Date of Web Publication13-Mar-2020

Correspondence Address:
Dr. Reshma Gopal Kini
Department of Pathology, Father Muller Medical College, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joah.joah_66_19

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  Abstract 

Dengue is predominantly a self-limiting illness. The association of dengue with new onset of leukemia has been rarely reported. We describe herein a series of three patients diagnosed with acute lymphoblastic leukemia, chronic myeloid leukemia, and acute promyelocytic leukemia who presented with concurrent dengue infection at a tertiary care institute in the southwestern coastal region of India. In spite of the different types of leukemias, we observed similar trends in their blood parameters, which were comparable with those of nonleukemic dengue patients. The transfusion profile of each of these patients is described. We could conclude that even in the presence of leukemia, dengue tends to be self-limited. No such comparative case reports have been published so far, and with an increasing incidence of dengue in the world, the occurrence of the two might not remain a remote possibility.

Keywords: Dengue, leukemia, lymphoblastic, myeloid, promyelocytic


How to cite this article:
Kini RG, Moras CB. The double jeopardy of leukemia and dengue: A report of three cases. J Appl Hematol 2020;11:25-8

How to cite this URL:
Kini RG, Moras CB. The double jeopardy of leukemia and dengue: A report of three cases. J Appl Hematol [serial online] 2020 [cited 2020 Jul 2];11:25-8. Available from: http://www.jahjournal.org/text.asp?2020/11/1/25/280547


  Introduction Top


Dengue has become ubiquitous with the World Health Organization, estimating 3.9 billion individuals at risk.[1],[2]

Classical dengue is a self-limiting disease. The risk of dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) is the highest. During days 2 to 10 of illness, and this period is considered critical. Synchronous diagnoses of dengue and leukemia are rarely reported; hence, the effect of one on another remains unexplored.[3],[4]


  Case Reports Top


Case 1

A 32-year-old male presented with fever of 5 days, melena, hepatosplenomegaly, and petechial rashes. The patient tested positive for immunoglobulin M (IgM) and IgG anti-dengue using the enzyme-linked immunosorbent assay. A diagnosis of DHF was considered. Laboratory investigations on the day of admission (Day 6) and subsequent days are presented in [Table 1]. Peripheral blood smear examination (PBSE) later in the day revealed atypical lymphocytes as well as 31% blasts. The diagnosis of acute lymphoblastic leukemia (ALL) was confirmed by flow cytometry. Serum transaminase levels were mildly elevated. The patient received eight units of random donor platelets (RDP) on the day of admission (day 6) and 2 units RDP on day 16 and required no further transfusions throughout the induction phase of chemotherapy.
Table 1: Hematological parameters of Case 1 from day 6 to day 13

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Case 2

A 61-year-old female presented with a fever of 5 days duration and had massive splenomegaly. Investigations on the day of admission and up to a week thereafter are represented in [Table 2]. PBSE showed the features consistent with chronic myeloid leukemia (CML) which was confirmed by the presence of P210 transcript. The patient became afebrile on day 10. She went on to have an unexceptional course during the treatment.
Table 2: Case 2 hematological parameters of Case 2 from day 6 to day 12

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Case 3

A 54-year-old male presented with excessive bleeding following tooth extraction. On the day of the presentation, the patient was seronegative for dengue. Hematological investigations throughout his admission are presented in [Table 3]. PBSE on the day of admission revealed leukoerythroblastic picture with 10% atypical cells. A diagnosis of acute promyelocytic leukemia (APML) was confirmed by the detection of PML/Rara transcript. He was started on arsenic trioxide on day 8 of admission and developed fever on day 11 (day 1 of illness). Fever continued unabated for 4 days. On day 8 of illness, he developed abdominal pain, acute breathlessness, and fall in blood pressure. Liver dysfunction became evident. The patient developed ascites and pleural effusion both of which are features of Dengue Shock Syndrome. The diagnosis of DSS was however not thought of uptil the time patient developed marked refractory thrombocytopenia and repeat test for dengue turned out to be positive. Prothrombin time and activated thromboplastin time and D-Dimer assays remained normal despite low fibrinogen levels. The patient died on the very same day.
Table 3: Laboratory parameters of Case 3

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  Discussion Top


Anemia, thrombocytopenia, leukopenia/leukocytosis with fever, and bleeding manifestations are the elements encountered in leukemias and dengue and can present a diagnostic dilemma.

The molecular pathogenesis of ALL, CML, and APML are different. However, during dengue, they showed similar trends in blood parameters. In all three cases, a gradual drop in white cell count (WCC) and platelet count (PC) was noted after 4–6 days of illness [Figure 1] and [Figure 2], i.e., during the critical period and the fall in PC was consistent despite RDP transfusion in cases 1 and 3. The trends of WCC and PC observed here are very similar to those of nonleukemic dengue patients observed by Chaloemwong et al.[5]
Figure 1: Trends in white cell count in Cases 1, 2 and 3

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Figure 2: Platelet counts in Cases 1, 2, and 3

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The interesting phenomenon in fall of blast counts which in all three cases hit nadir on day 9 rather confirms the marrow suppressive nature of dengue [Figure 3].
Figure 3: Trends in blast counts in Cases 1, 2, and 3 showing gradual decrease from day 6 to 9

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Hemoglobin and hematocrit paralleled each other and at no point showed a warning sign of DHF or DSS. Elevated transaminase levels which is a strong predictor for DSS was seen only in case 3.[6]

Garcia et al. reported refractoriness of the PC in acute myeloid leukemia with dengue. Our observation was similar in Case 3. Commencement of chemotherapy after hematological recovery from dengue (critical period) in Case 1 might be the cause of why he required lesser number of transfusions as opposed to Case 3. Furthermore, in APML, loss of the promyelocytic-leukemia-gene product, which is an important restriction factor against dengue viruses, may have blunted the host defense[7]


  Conclusion Top


Dengue must be tested for in patients with leukemia who have cytopenia that are unresponsive to transfusion. Blood parameters irrespective of the type of leukemia show comparable trends during dengue episodes. The critical period for dengue is during 4–10 days of illness, and prompt diagnosis of both diseases with supportive treatment determine the outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
World Health Organization. Epidemiology. World Health Organization; 2019. Available from: https://www.who.int/denguecontrol/epidemiology/en/. [Last accessed on 2019 Oct 16].  Back to cited text no. 1
    
2.
National Guidelines for Clinical Management of Dengue Fever; 2014. Available from: http://www.pbhealth.gov.in/Dengue-National-Guidelines-2014%20Compressed.pdf. [Last accessed on 2019 Oct 16].  Back to cited text no. 2
    
3.
Dengue and Dengue Hemorrhagic Fever; 2009. Available from: https://www.cdc.gov/dengue/resources/denguedhf-information-for-health-care-practitioners_2009.pdf. [Last accessed on 2019 Oct 16].  Back to cited text no. 3
    
4.
Garcia L, Dias D, Bellesso M, Vargas J, Aranha M, Lopes A. Fight for platelets: AML diagnosed during dengue fever: Case report. Blood 2015;126:4903.  Back to cited text no. 4
    
5.
Chaloemwong, J.; Tantiworawit, A.; Rattanathammethee, T.; Hantrakool, S.; Chai-Adisaksopha, C.; Rattarittamrong, E.; Norasetthada, L. Useful clinical features and hematological parameters for the diagnosis of dengue infection in patients with acute febrile illness: A retrospective study. BMC Hematol. 2018, 18: 20.  Back to cited text no. 5
    
6.
Tewari K, Tewari VV, Mehta R. Clinical and hematological profile of patients with dengue fever at a tertiary care hospital – An observational study. Mediterr J Hematol Infect Dis 2018;10:e2018021.  Back to cited text no. 6
    
7.
Giovannoni F, Damonte EB, García CC. Cellular promyelocytic leukemia protein is an important dengue virus restriction factor. PLoS One 2015;10:e0125690.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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