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Updated: Dec 27 2021

Acute Myelogenous Leukemia (AML)

Images cell differential - 1.jpg
  • Snapshot
    • A 63-year-old man presents with fever, increasing fatigue, and actively bleeding gums. Physical exam also reveals several oral mucosal petechiae. His CBC reveal decreased platelet and hemoglobin. His PT and PTT are elevated with low fibrinogen. Peripheral blood smear shows blasts and schistocytes. His D-dimer level is elevated. He is diagnosed with DIC and given fresh frozen plasma. He is referred to a hematologist-oncologist.
  • Introduction
    • Acute leukemia resulting in bone marrow failure from neoplastic proliferation
    • Subtypes
      • M3 aka acute promyelocytic leukemia (APL)
        • t(15;17)
          • disruption of retinoic acid receptor (RAR) required for myeloblast maturation
        • associated with DIC
        • presence of Auer rods
          • peroxidase-positive cytoplasmic inclusions
      • acute megakaryoblastic leukemia
        • associated with Down syndrome
        • < 5 years (recall leukemia in Down syndrome occurring in > 5 years = ALL)
      • acute monocytic leukemia
        • infiltration of gums
  • Epidemiology
    • Median onset 65 years of age
    • Risk factors
      • alkylating chemotherapy
      • radiation
      • myeloproliferative disorders
      • Down syndrome
      • smoking
  • Presentation
    • Symptoms of pancytopenia (high WBC count but WBCs are dysfunctional)
      • fatigue
      • dyspnea
      • infection due to dysfunctional blasts
      • bleeding
    • Physical exam
      • lymphadenopathy (infiltration of leukemia)
      • hepatosplenomegaly (infiltration of leukemia)
      • fever
      • swollen gums (infiltration of leukemia)
    • Best initial test - peripheral blood smear
      • > 20% blasts in blood smear
    • Most accurate test
      • flow cytometry
    • Bone marrow biopsy with cytogenetics
      • myeloblasts with Auer rods in APL
      • myeloperoxidase positive in APL, negative in other subtypes
    • Labs - CBC
      • ↓ RBCs
      • ↓ mature WBCs
      • ↓ platelets
  • Differential Diagnosis
    • ALL
    • Myelodysplastic syndrome
    • CML blast crisis
    • Leukemoid reaction
  • Treatment
    • Initial treatment with chemotherapy
      • to induce remission
      • cytarabine
    • Bone marrow transplant after remission
      • especially for cytogenetics revealing high chance of relapse
    • All-trans-retinoic acid (ATRA) to those with M3 (APL)
  • Complications
    • Febrile neutropenia
    • DIC (especially with APL)
    • Gout
    • Tumor lysis syndrome
  • Prognosis
    • Prognostic indicator is cytogenetics
    • 90% complete response rate from initial chemotherapy in those with good cytogenetics
    • Relapse rate > 50% with median survival 3-12 months
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