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 Table of Contents  
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 41-43

A rare presentation of childhood acute lymphoblastic leukemia with hypereosinophilia lacking peripheral blood smear leukemic cells

Clinical Pathology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission01-Jul-2020
Date of Decision14-Sep-2020
Date of Acceptance18-Sep-2020
Date of Web Publication15-Mar-2021

Correspondence Address:
Dr. Ahmed I Yakoub
Clinical Pathology Department, Faculty of Medicine, Zagazig University, Zagazig
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joah.joah_108_20

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Presentation of childhood acute lymphoblastic leukemia (ALL) with hypereosinophilia is rare and may be confusing, especially in the absence of blasts on examination of the peripheral blood film. It is usually associated with cytogenetic abnormalities. Hypereosinophilic childhood ALL has a poor prognosis requiring prompt clinical intervention. A case of 10-year-old boy presented to our hospital with a high fever not responding to treatment and hypereosinophilia in the peripheral blood, diagnosed later as childhood ALL.

Keywords: Acute lymphoblastic leukemia, eosinophilia, hypereosinophilia

How to cite this article:
Yakoub AI. A rare presentation of childhood acute lymphoblastic leukemia with hypereosinophilia lacking peripheral blood smear leukemic cells. J Appl Hematol 2021;12:41-3

How to cite this URL:
Yakoub AI. A rare presentation of childhood acute lymphoblastic leukemia with hypereosinophilia lacking peripheral blood smear leukemic cells. J Appl Hematol [serial online] 2021 [cited 2021 Aug 5];12:41-3. Available from: https://www.jahjournal.org/text.asp?2021/12/1/41/311325

  Introduction Top

Eosinophilia is not an uncommon presentation on reporting complete blood count. This, in combination with symptoms and signs serves as an important clue for clinical diagnosis.[1] Mild eosinophilia is defined as absolute eosinophils count ranging from 0.5 to 1.0 × 109/L, whereas hypereosinophilia is defined as absolute eosinophils count ≥1.5 × 109/L. Hypereosinophilia is rare, requiring investigation of the underlying cause.[2]

Hypereosinophilia is frequently reported in allergic reactions, helminthic infections, and some hematological malignancies, including Hodgkin's lymphoma, chronic myeloid and acute lymphoblastic leukemia (ALL).[3]

Polyclonal eosinophil expansion is more common and occurs as a reaction to increased production of interleukin-5 (IL-5). In this case, eosinophilia is said to be ”reactive” or ”secondary.” Rarely, the eosinophilic expansion is clonal as a result of hematopoietic stem cell mutation. Cytogenetic abnormality can affect mainly eosinophils, for example, in acute or chronic eosinophilic leukemia or involve many cell-types, for example, chronic myelomonocytic leukemia or systemic mast cell disease.[4]

  Case Report Top

A 10-year-old boy presented to the outpatient clinic of pediatrics in Zagazig university hospitals complaining of fever and flushing started 10 days ago, not responding to treatment. Routine complete blood count was done, which revealed white blood count of 80.0 × 10^3/uL, platelet count of 107.0 × 10^3/uL, and hemoglobin concentration of 7.8 g/dl. A peripheral blood smear revealed eosinophilia of 82% with many hypogranular forms [Figure 1]. The patient was admitted, and other investigations were done, as shown in [Table 1]. Pelvi-abdominal ultrasound revealed mild splenomegaly. Bone marrow aspiration from iliac bone was performed. Leishman stained bone marrow slides revealed blast cells 41% and eosinophils 14% [Figure 2]. Flow cytometry analysis of the bone marrow sample revealed positive CD 19, CD 22, CD 79a, CD 34, and CD 10, while it was negative for CD 20, CD 13, CD 14, CD3, and myeloperoxidase. Results of flow cytometry are consistent with common ALL of B-lineage ALL. The patient was transferred to the oncology unit of pediatrics the protocol of chemotherapy relevant to his case was started. At the end of the first cycle, complete remission was achieved. All investigations were done after an informed consent from parent and assent from the child.
Table 1: Laboratory results of patient

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Figure 1: Stained smear of peripheral blood showing hyogranular eosinophils with absence of blasts

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Figure 2: Stained smear of bone marrow aspirate showing predominately lymphoblasts and number of eosinophils

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  Discussion Top

Hypereosinophilia was reported in ALL but with very low incidence. The disease was first described by Spitzer and Garson in 1973.[5]

After their description, over 50 cases of ALL in children and adults of hypereosinophilia presentation were documented in the literature,[6] most of them were B lineage ALL.[7]

Common presenting manifestations of ALL may be preceded by eosinophilia for several weeks or even months.[5] Furthermore, symptoms and signs may be different from those used to be seen in ALL, and this may be due to clinical manifestations of eosinophilic infiltration of different body organs.[8]

A chromosomal translocation, t(5;14)(q31;q32), is the most common chromosomal abnormality found in ALL with eosinophilia, resulting in the generation of a fusion gene IL3 IgH.[9] However, the number of cases with such cytogenetic abnormality is very small, and different chromosomal aberrations have also been detected.[6]

Cytogenetic analysis, in this case, showed normal 46, XY karyotype, but molecular diagnostic studies were not performed.

One of the most challenging points in hypereosinophilic ALL is a failure to detect blasts in peripheral blood, which may delay the diagnosis of this rare subtype and may waste time taken for differential diagnosis with other causes of hypereosinophilia

Hypereosinophilic syndrome, one of the causes of hypereosinophilia, may lead to fatal organ damage resulting from eosinophilic infiltration. Thrombocytopenia can be seen too at presentation.[8]

Although complications of bone marrow aspiration and trephine biopsy are rare, they are documented, and the most serious complication is hemorrhage.[10]

The decision for bone marrow aspiration in our case relayed on thrombocytopenia and marked leukocytosis in the presence of prolonged fever not responding to treatment. Bone marrow aspiration was crucial for the detection of hidden malignancy.

  Conclusion Top

In summary, bone marrow aspiration should be considered in cases with hypereosinophilia, especially in the presence of dysplastic hypogranular eosinophils and in the absence of reactive causes.

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.

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Conflicts of interest

  References Top

Simon HU, Rothenberg ME, Bochner BS, Weller PF, Wardlaw AJ, Wechsler ME, et al. Refining the definition of hypereosinophilic syndrome. J Allergy Clin Immunol. 2010;126:45 9.  Back to cited text no. 1
Andersen CL, Siersma VD, Hasselbalch HC, Lindegaard H, Vestergaard H, Felding P, et al. Eosinophilia in routine blood samples and the subsequent risk of hematological malignancies and death. Am J Hematol 2013;88:843-7.  Back to cited text no. 2
Valent P, Klion AD, Horny HP, Roufosse F, Gotlib J, Weller PF, et al. Contemporary consensus proposal on criteria and classification of eosinophilic disorders and related syndromes. J Allergy Clin Immunol 2012;130:607-12.  Back to cited text no. 3
Roufosse F, Weller PF. Practical approach to the patient with hypereosinophilia. J Allergy Clin Immunol 2010;126:39-44.  Back to cited text no. 4
Spitzer G, Garson OM. Lymphoblastic leukemia with marked eosinophilia: A report of two cases. Blood 1973;42:377-84.  Back to cited text no. 5
Bhatti FA, Hussain I, Ali MZ, Adult B. Lymphoblastic leukaemia/lymphoma with hypodiploidy (-9) and a novel chromosomal translocation t(7;12)(q22;p13) presenting with severe eosinophilia - Case report and review of literature. J Hematol Oncol 2009;2:26-9.  Back to cited text no. 6
Wilson F, Tefferi A. Acute lymphocytic leukemia with eosinophilia: Two case reports and a literature review. Leuk Lymphoma 2005;46:1045-50.  Back to cited text no. 7
Schwartz JT, Fulkerson PC. An approach to the evaluation of persistent hypereosinophilia in pediatric patients. Front Immunol 2018;9:1944.  Back to cited text no. 8
Meeker TC, Hardy D, Willman C, Hogan T, Abrams J. Activation of the interleukin-3 gene by chromosome translocation in acute lymphocytic leukemia with eosinophilia. Blood 1990;76:285-9.  Back to cited text no. 9
Bain BJ. Bone marrow biopsy morbidity and mortality. Br J Haematol 2003;121:949-51.  Back to cited text no. 10


  [Figure 1], [Figure 2]

  [Table 1]


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