Acute lymphoblastic leukemia with eosinophilia

Myeloproliferative Syndrome With Eosinophilia Associated With Translocation t(8; 13) and T-cell Lymphoblastic Lymphoma: A Case Report and Review of the Literature

The 8p11 myeloproliferative syndrome (EMS) is an aggressive neoplasm associated with chromosomal translocations involving the fibroblast growth factor receptor 1 tyrosine kinase gene on chromosome 8p11. We report the case of a 31-year-old man with no prior medical history who presents with two weeks of sore throat and cervical lymphadenopathy up to 5 cm. Initial peripheral blood examination showed leukocytosis with predominantly neutrophils and eosinophilia. A CT scan demonstrated mediastinal lymphadenopathies, liver enlargement and splenomegaly. An excisional biopsy of a cervical lymph node demonstrated findings consistent with a diagnosis of T-cell lymphoblastic lymphoma. Bone marrow aspirate and biopsy revealed hypercellular marrow with granulocytic predominance, left-shifted granulopoiesis, eosinophilia and the cytogenetic analysis showed the following karyotype: 46, XY, t(8;13). The final diagnosis was a myeloproliferative syndrome with eosinophilia related to t(8;13) and T-cell acute lymphoblastic lymphoma (8p11 myeloproliferative syndrome). We review the relevant literature about this unusual entity.

Eosinophils from Physiology to Disease: A Comprehensive Review

Despite being the second least represented granulocyte subpopulation in the circulating blood, eosinophils are receiving a growing interest from the scientific community, due to their complex pathophysiological role in a broad range of local and systemic inflammatory diseases as well as in cancer and thrombosis. Eosinophils are crucial for the control of parasitic infections, but increasing evidence suggests that they are also involved in vital defensive tasks against bacterial and viral pathogens including HIV. On the other side of the coin, eosinophil potential to provide a strong defensive response against invading microbes through the release of a large array of compounds can prove toxic to the host tissues and dysregulate haemostasis. Increasing knowledge of eosinophil biological behaviour is leading to major changes in established paradigms for the classification and diagnosis of several allergic and autoimmune diseases and has paved the way to a "golden age" of eosinophil-targeted agents. In this review, we provide a comprehensive update on the pathophysiological role of eosinophils in host defence, inflammation, and cancer and discuss potential clinical implications in light of recent therapeutic advances.

Hypereosinophilia in Acute Lymphoblastic Leukemia: Two Cases with Review of Literature

Eosinophilia is rare in acute leukemia at presentation. Discrete reports and case studies in recent years have created significant interest in the field of "Acute leukemia with eosinophilia". We herein present two cases of eosinophilia in association with acute lymphoblastic leukemia with brief review of literature in this field. First case is about 21-year-old female who presented with mediastinal mass along with leukocytosis and hypereosinophilia. On evaluation, she was found to have T cell acute lymphoblastic leukemia. After ruling out benign causes of eosinophilia, she was treated with modified BFM-90 protocol. Her eosinophilia resolved after 4 weeks of induction therapy. Second case is about 32-year-old male who was diagnosed as a case of mixed phenotype leukemia (B cell/myeloid type) along with severe eosinophilia. His hypereosinophilia finally resolved by week 16 of modified BFM-90 protocol. Diagnosing ALL is challenging when eosinophilia is the initial presentation. These two cases emphasize on the importance of considering ALL amongst one of the etiological causes of eosinophilia as delay in diagnosis endangers patient's life at risk. Also eosinophilia per se is an independent poor risk factor, hence prompt diagnosis and early treatment is the key in all such cases.

Eosinophilic presentation of acute lymphoblastic leukemia

Patient: Male, 5

Primary Diagnosis: Rule-out appendicitis

Co-existing Diseases: Acute lymphoblastic leukemia (ALL)

Medication: Chemiotherapy

Clinical Procedure: Chest CT • flow cytometry

Specialty: Pediatrics’ oncology • infection diseases

Hyper-eosinophilia in granular acute B-cell lymphoblastic leukemia with myeloid antigen expression

Acute lymphoblastic leukemia with eosinophilia (ALLEo) is a rare but a distinctive clinical entity. Clinical features of idiopathic hyper-eosinophilic syndrome (HES) can be seen in patients with ALLEo. We report a 10-year-old girl, in whom HES was initially suspected but further investigation confirmed the diagnosis of acute B-cell lymphoblastic leukemia with myeloid antigen expression. Clinical response to chemotherapy was excellent with achievement of complete remission for 4 years. Serum interleukin-3 and -5 were elevated at presentation and normalized with disappearance of eosinophilia after induction therapy, supporting the reactive nature of eosinophilia in ALLEo. Hematologic malignancy should be considered in patients with hyper-eosinophilia, before attributing it to HES.

Lymphoproliferative disorders associated with hypereosinophilia

Hypereosinophilia, defined as peripheral blood eosinophil counts > 1,500/μL, may complicate the course of various lymphoproliferative disorders. Among these, Hodgkin lymphoma (HL) and certain peripheral T-cell lymphomas (PTCLs) derived from CD4 cells, including Sezary syndrome (SS), adult T-cell leukemia/lymphoma (ATLL), and angioimmunoblastic T-cell lymphoma (AITL), are most commonly associated with increased reactive eosinophilopoiesis. Rarely, marked hypereosinophilia (HE) may occur in the setting of acute B-cell lymphoblastic leukemia, with a substantial impact on disease course. The mechanisms leading to blood and tissue eosinophilia in the setting of lymphoproliferative disorders, as well as the clinical complications and prognostic implications of hypereosinophilia, are discussed in this review.

Severe Eosinophilia in an infant with congenital acute myeloid leukemia with t(3;4;6)(q26;q25;q21): a case report

We report a case of acute myeloid leukemia with morphologic features of M7 according to the FAB (French-American-British) classification and severe eosinophilia in the peripheral blood and bone marrow at diagnosis. We consider it as congenital leukemia, as the symptoms started in the first month of life of the affected child. This case of leukemia is characterized by t(3;4;6)(q26;q25;q21) cytogenetic abnormality. The blasts in flow cytometry analysis expressed markers of megakaryocytic lineage along with expression of myeloperoxidase in 30% of them. This type of acute myelogenous leukemia with severe eosinophilia can be considered as a distinct clinicopathologic entity.

Acute lymphoblastic leukemia presenting with urticarial plaques and hypereosinophilia in a child

Our report describes a previously healthy 10-year-old female who was seen for urticarial plaques and mild loss of appetite. An initial laboratory workup revealed an elevated leukocyte count of 30,000/microL and a peripheral eosinophil count of 22,500/microL. A skin biopsy showed a marked hypersensitivity tissue response with abundant eosinophils. Further investigation of her peripheral eosinophilia uncovered Giardia lamblia in a stool sample. Despite treatment with the anti-parasitic agent furazolidone, the patient's urticarial plaques, leukocyte count, and peripheral eosinophil count remained unchanged. A bone marrow biopsy confirmed a diagnosis of acute lymphoblastic leukemia (ALL). ALL with hypereosinophilia (ALL/Eo) represents a rare and distinct subset of ALL, with more than 30 cases documented in the literature. Our discussion summarizes the clinical aspects of this disease and reviews the reported dermatological manifestations of ALL/Eo.

In situ eosinophil activation in 26 primary cutaneous T-cell lymphomas with blood eosinophilia

Blood and tissue eosinophils can be associated with Hodgkin and non-Hodgkin lymphomas in that they have prognostic value. Tissue eosinophils in T-cell lymphoma patients with blood eosinophilia have not been systematically assessed. The objective of this research was to study the presence, density, and activation of tissue eosinophils in patients with primary cutaneous T-cell lymphomas (CTCLs) with blood eosinophilia and a possible relationship between features of the disease and prognosis. With skin biopsy specimens from 26 CTCL patients with blood eosinophilia, tissue eosinophils were studied with electron microscopy, extracellular eosinophil peroxidase deposits, and interleukin-5 expression. Tissue eosinophils, found in 22 of 26 cases, were constantly activated. Both density and activation of tissue eosinophils were significantly related to disease progression. The state of activation of tissue eosinophils in CTCL might reflect inflammatory flare-ups associated with aggressive lymphomas. Further studies are needed to confirm the value of eosinophil density as a simple and reliable marker of CTCL progression.

Urticarial lesions in a child with acute lymphoblastic leukemia and eosinophilia

The hypereosinophilic syndrome (HES) is defined by a longer than 6-month history of peripheral blood hypereosinophilia (greater than 1.5 x 10(9)/L), with signs and symptoms of internal organ involvement, in the absence of an identifiable cause. HES is therefore a diagnosis of exclusion. Patients have been reported who initially met the criteria for HES but subsequently developed a rare hematologic malignancy known as acute lymphoblastic leukemia with eosinophilia (ALL-Eo). We report such a case in a 10-year-old boy who presented to the pediatric dermatology clinic with unusual, urticarial skin lesions. Although skin involvement is often reported in cases of HES and ALL-Eo, such findings are variable and reports in the dermatology literature are few. We emphasize the importance of continuous monitoring for underlying malignancy in children with urticarial skin lesions in the setting of unexplained hypereosinophilia.

Acute lymphoblastic leukemia with hypereosinophilia: report of a case with 5q deletion and review of the literature

Peripheral blood eosinophilia as a presentation of acute lymphoblastic leukemia (ALL) has only rarely been reported. The eosinophilia is thought to be a nonneoplastic reaction to the neoplastic lymphoblasts. We present the case of a 5-year-old girl who developed peripheral hypereosinophilia with no circulating blasts prior to her diagnosis of B-cell lineage ALL. Cytogenetic study showed a hyperdiploid blast population with 5q deletion. Persistent peripheral hypereosinophilia should always be fully investigated, the possibility of a malignancy including ALL needs to be excluded, even in the absence of peripheral cytopenias and circulating blasts.

Metastatic carcinoma presenting with concomitant eosinophilia and thromboembolism

A case of a 58-year-old female patient who presented with significant blood eosinophilia and thromboembolic events is described. The patient was eventually diagnosed as suffering from a disseminated malignancy of gastrointestinal origin. Immunohistochemical studies of the tumor are presented. These studies show that tumor cells produce interleukin-3 and -5 and granulocyte macrophage-colony stimulating factor. These cytokines are known to support differentiation, proliferation, and survival of eosinophils. Their secretion is the probable explanation for the appearance of high blood eosinophilia in this patient. To the best of our knowledge, combined blood eosinophilia and thromboembolism as presenting manifestations of a solid tumor have never been reported.

Molecular monitoring of cerebrospinal fluid can predict clinical relapse in acute lymphoblastic leukemia with eosinophilia

In a patient with precursor B-cell acute lymphoblastic leukemia (ALL) associated with eosinophilia that completely responded to induction chemotherapy, we assayed serial remission cerebrospinal fluid and bone marrow specimens for minimal residual disease using a quantitative polymerase chain reaction assay to assess for clone-specific immunoglobulin heavy-chain gene cluster (IGH) gene rearrangement. Cerebrospinal fluid eosinophilia and minimal residual disease were detected on day 406, preceding the morphologic diagnosis of central nervous system relapse on day 578. By day 841, the bone marrow had 35% blasts. Despite aggressive therapy, including unrelated umbilical cord blood transplantation, the patient developed testicular and bone marrow relapses and died of disease. We conclude that increasing levels of minimal residual disease in cerebrospinal fluid can predict recurrence of ALL prior to clinical and morphologic relapse. Furthermore, we demonstrate a novel translocation in this tumor, the t(5;9)(q31;p24), that possibly led to fusion of the interleukin-3 (IL3) (5q31) and JAK2 (9p24) genes and may explain the concomitant appearance of eosinophilia and ALL.

A practical workup for eosinophilia. You can investigate the most likely causes right in your office

The vast majority of cases of eosinophilia in North America are caused by allergic processes. In individual cases, a short differential diagnosis of the most likely causes can be formulated on the basis of the absolute eosinophil count. The extensive laboratory workup previously recommended by some authorities is probably not justified unless detailed history taking and physical examination indicate a need for specific investigations. Although the possibility of missing an occult neoplasm has been used to justify extensive investigation, this is usually not necessary because most tumor-associated eosinophilia is accompanied by widely metastatic disease. History taking should emphasize the possibility of drug-induced or helminth-associated eosinophilia. If the history indicates travel, dietary, or other exposure risks, stool examination for ova and parasites is worthwhile. If a possible allergic cause is suspected, testing for evidence of atopy may be performed concomitantly with testing for parasitic infection. A follow-up white blood cell count with differential is recommended to ascertain whether eosinophilia has resolved. When an absolute eosinophil count of more than 1.5 x 10(9)/L persists for longer than 6 months, idiopathic hypereosinophilic syndrome must be ruled out.

A case of pleomorphic T-cell lymphoma with a high content of reactive histiocytes presented with hypereosinophilia

A case of peripheral T-cell lymphoma classified, according to the updated Kiel classification, as a large pleomorphic T-cell lymphoma with a high content of reactive histiocytes and blood hypereosinophilia is reported. Light microscopic examination revealed a diffuse effacement of the lymph node structure by large pleomorphic lymphoma cells mixed with eosinophils and many histiocytes, some of them presenting discrete features of hemophagocytosis. The neoplastic cells were CD3, CD5, CD8 and HLA-DR positive but failed to show CD30 antigen. DNA molecular analysis displayed simultaneous rearrangements of the genes coding for the delta chain of the T-cell receptor and for the Ig heavy chain. Increased serum levels of angiotensin converting enzyme and ferritin were found and probably induced by the reactive histiocytes. Immunoassays (ELISA) with antibodies directed against some cytokines and against the Tac peptide (sIL-2R) were performed. They demonstrated high serum levels of sIL-2R and a slight increase in GM-CSF, but neither IL-5 nor IL-3. The association of blood hypereosinophilia and histiocytic hyperplasia with a peripheral T-cell lymphoma is discussed.

Morphological, ultrastructural, and genetic characterization of an unusual T-cell lymphoma in a patient with sinus histiocytosis with massive lymphadenopathy

Sinus histiocytosis with massive lymphadenopathy (SHML) is a rare benign disease of unknown etiology. It is rarely associated with malignant lymphoma. This report documents the first case of a T-cell lymphoma, which developed in a patient with a 10-year history of SHML. The disease was complicated by hypereosinophilia and massive retroperitoneal lymphadenopathy. Histological examination of a cervical lymph node biopsy during the terminal phase identified a lymphoma composed of cells with morphological plasmacytoid features. Ultrastructurally, the tumor cells showed poorly developed cytoplasm, nuclei with peripheral chromatin clumping, and inconspicuous nucleoli. Cytogenetic studies showed two related clones. On immunohistochemical staining tumor cells were positive with monoclonal antibodies (mAb) CD3 and CD45RO. Southern blotting analysis identified clonal rearrangements in the T-cell receptor (TCR) alpha, beta and gamma genes. Thus, T-cell lineage of the tumor cells was established. In situ hybridization of interleukin-2 (IL-2) and interleukin-5 (IL-5) cDNA probes on tissue sections identified the synthesis of IL-5 by the eosinophils, suggesting an autocrine pathway of eosinophilopoiesis leading to hypereosinophilia in this patient.

Myelodysplastic syndrome with bone marrow eosinophilia: clinical and cytogenetic features

We investigated the hematological and clinical status of 145 patients with de novo myelodysplastic syndrome (MDS), 14 of whom (10%) had eosinophilia in the bone marrow (MDS-Eo). Most of these 14 patients had severe anemia. Their bone marrow cells exhibited trilineage dysplasia and some morphological abnormalities in the eosinophils, including disproportion of eosinophilic granules, basophilic granules, a ring-shaped nucleus, and vacuolation in the cytoplasm. However, these abnormalities were less prominent than those of acute myelomonocytic leukemia with eosinophilia (FAB: M4Eo). Three of the 14 MDS-Eo patients had refractory anemia (RA), seven had RA with excess of blasts (RAEB), and four had RAEB in transformation. Cytogenetic analysis revealed chromosomal abnormalities in 12 of 13 MDS-Eo patients (92%), in particular, there were major karyotypic abnormalities (MAKA) in eight patients (62%). Cytotoxic agents were not effective in the treatment of four patients after leukemic transformation occurred. These four patients died of the leukemic transformation while seven died of bone marrow failure. The other three MDS-Eo patients are still alive; two of them have already transformed to a leukemic phase. The duration of survival of these patients was significantly shorter than that of the other MDS patients. These findings suggest that bone marrow eosinophilia in MDS may be a poor prognostic factor that is strongly related to the existence of MAKA.

[Eosinophil and its pathology]

Hypercosinophilia was previously considered as a biological marker, particularly useful for diagnostic investigation. However, it can also appear as a marker of disease activity since fundamental studies have revealed the potent pathogenic role of human eosinophils. This new appreciation is related to a better definition of the molecular and cellular basis of eosinophil functions. Thus, eosinophils were identified as inflammatory and/or cytotoxic cells after the characterization of the role of surface molecules (adhesion molecules, Fc receptor of immunoglobulins) and mediators. The molecular components which endow the eosinophil with certain of its functional characteristics are primarily the cationic proteins of the specific granules and the phospholipid mediators that are newly formed during cellular activation. Some of these effector molecules are also directly involved in the induction of deleterious effects.

Role of granulocyte-macrophage colony-stimulating factor, interleukin-3 and interleukin-5 in the eosinophilia associated with T cell lymphoma

We studied two patients with a leukaemic T cell lymphoma who presented with a marked increase in blood eosinophilia. To investigate the mechanism of the eosinophilia, supernatants of peripheral blood cells containing more than 80% lymphoma cells were tested by biological assays for the presence of colony stimulating factors (CSF). In one case supernatants stimulated the growth of granulocyte-macrophage (GM), erythroid and eosinophil colonies. These effects were neutralized by anti-GM-CSF antibodies; anti-IL5 antibodies slightly decreased eosinophil colony formation. Supernatants derived from the second patient cells stimulated the same lineages. Neutralizing experiments demonstrated that in addition to GM-CSF it contained interleukin 3 (IL-3) and interleukin 5 (IL-5). In agreement with the biological data, RNA studies using the polymerase chain reaction showed that cells from the first patient expressed GM-CSF transcripts; IL-5 transcripts were also detected in very low amounts. GM-CSF, IL-3 and IL-5 transcripts were detected in cells from the second patient. Thus eosinophilia associated with some T cell lymphoma is likely due to secretion of different combinations of cytokines by malignant cells.

Temporal association of marrow eosinophilia with inversion of chromosome 16 in recurrent blast crises of chronic myelogenous leukemia

We report a patient with Ph+ chronic myelogenous leukemia (CML) whose recurrent blast crises were associated with marrow eosinophilia and inv(16). After intensive chemotherapy, for each blast crisis, the patient reentered chronic phase with disappearance of both the inv(16) and the eosinophilia.