A diagnostic dilemma in the emergency room: intracranial hemorrhages in acute myeloblastic leukemia with hyperleukocytosis

Excerpt

A 80-year-old woman was admitted to the emergency department with nausea, vomiting, and loss of consciousness. A cranial computed tomography demonstrated subtle hypodense areas and multiple intracranial hemorrhages (Fig. 1). A conventional and advanced magnetic resonance (MR) imaging, including susceptibility-weighted imaging (SWI) was then performed to make a differential diagnosis of the simultaneous intraparenchymal hemorrhages. MR imaging demonstrated numerous cortical and subcortical intraparenchymal hemorrhages with mild vasogenic edema, which were best seen on SWI (Fig. 2). There was an active contrast extravasation into the left putaminal hematoma, but with no associated enhancement on contrast-enhanced MR image (Fig. 3). Laboratory studies revealed a white blood cell count of 471 × 10⁹/l, hemoglobin count of 6.4 g/l and platelet count of 77 × 10⁹/l. The patient’s lactate dehydrogenase level and serum uric acid level were 5866 U/l and 10.1 mg/dl, respectively. A peripheral blood smear revealed a very high number of blasts (97% of nucleated elements). Peripheral blood findings did not show any evidence of disseminated intravascular coagulopathy. Bone marrow smear revealed acute myeloid leukemia M4. Despite immediate treatment, she died 6 days later. …