This case report describes a 3-year-old female patient presenting with bleeding symptoms including rashes, nosebleeds, gum bleeding, and bloody stools. Initial investigations revealed pancytopenia. The peripheral smear and bone marrow findings were suggestive of idiopathic thrombocytopenic purpura with evidence of infection rather than acute promyelocytic leukemia due to the absence of features such as organomegaly and specific immunophenotyping or cytogenetic findings. The patient was treated with antibiotics and supportive care and diagnosed with idiopathic thrombocytopenic purpura complicated by infection based on clinical presentation, investigations, and differential diagnosis workup.

1. D R . P R I YA N K A YA D AV
D R . V A I B H AV M O D I
CASE REPORT
MIMICKING APML
A DIAGNOSTIC CONFUSION

2. LAYOUT
• Case report
• Investigations
• Peripheral smear
• Bone marrow
• Differential Diagnosis
• Further Approach

3. CASE REPORT
• 3 year old female patient
• Complaints :
 Bluish red rashes over body
 Bleeding from nose and gums
 Subconjunctival bleed on minor trauma
 Reddish brown stools
since 2 days
No family history of bleeding

4. CASE REPORT…
• On examination:
 Pallor
 Ecchymoses & purpuric rashes all over body
 No oraganomegaly/ lymphadenopathy
• CBP Platelets –
Hemoglobin – 9.3 g/dl
Total WBC - 22,600 cells/cumm
Differential - N 36 L60 E02 M02 B00
Platelets - 13,000 /cumm

5. • BT : > 10 min; CT: 5.5 min
• PT, APTT : WNL
• LFT & RFT : WNL
CASE REPORT…

6. PS COMMENT
Hb: 9.3g/dl
RBC series:
• Mild anisopoikilolocytosis
with moderate hypo-
chromia
• Nucleated RBCs –
4/100 WBCs

7. PS COMMENT
WBC series:
• Total WBC -
22,600 cells/cu mm
• Differential - N
36 L60 E02 M02 B00
• Shift to left seen in myeloid
series
• Occassional Blast cells
seen

8. PS COMMENT
BLAST CELLS ?
myeloblast
• Some had coarse
azurophilic granules
• At places, auer rod like
structures in cytoplasm
? Artifact
? Toxic granules
? Promyelocytes

9. PS COMMENT
Platelets:
• Markedly reduced – less
than 10,000/cumm
• Morphologically normal

10. PS COMMENT- IMPRESSION
• Clinical picture ; age, bleeding **
• Anemia
• Leukocytosis with shift to the left**
• Thrombocytopenia
? Acute Promyelocytic Leukemia
? Infection
Important to rule out Acute Promyelocytic Leukemia
- Hematological emergency
Our Diagnosis: Infection
Follow up was advised.

11. FURTHER CLINICAL COURSE
• Antibiotics (Cephalosporins) and supportive treatment
• 6 transfusions (2 PRCs and 4 RDP)
• In one week, no improvement
• Platelet count still low
Patient was sent for review and for Bone Marrow Examination

12. REPEAT PERIPHERAL SMEAR

13. REPEAT PERIPHERAL BLOOD/ SMEAR
1st PS REPEAT PS
Hemoglobin 9.3gm/dl 8.9 g/dl
RBC Series Normocytic
hypochromic
Normocytic
hypochromic
Total WBC 22,600 cells/cumm 17,600 cells/cumm
Differential N 36 L60 E02 M02 B00 N 65 L30 E02 M03 B00
Blasts +
Promyelocytes
11% 4%
Toxic granulation in
neutrophils
Few Large number
Platelets Markedly reduced Markedly reduced

14. BONE MARROW ASPIRATION
• Marrow- normocellular
• M:E ratio – 2:1
• Eryhthroid series:
Reaction pred.
normoblastic with
megaloblastoid
changes
Marrow - easy to aspirate

15. BONE MARROW ASPIRATION
Myeloid series-
• Shift to left – (myelocytes
and metamyelocytes –
38%)
• Myelocytes and
metamyelocytes showing
heavy toxic granulations
• Percentage of blasts and
promyelocytes– 08%
• No Auer rods seen in blasts

16. BONE MARROW ASPIRATION
Megakaryocytes
• Increased in number
• Few loose clusters
• Few showing
cytophagocytosis

17. BONE MARROW ASPIRATION
Plasma cells
• Within normal limits
Reticulum cells
• Within normal limits
Iron : 3 (+++)
Hemoparasite : none

18. DIFFERENTIAL DIAGNOSIS
Diagnosis: ITP with INFECTION
D/D:
• APML
• ALL
• HEMATOGONES
• VIRAL INFECTION
• Myelodysplastic Syndrome

19. ACUTE ITP
Points FOR:
• Age
• Clinical presentation
• PS: Thrombocytopenia
• BM:
 ↑ megakaryocytes
 Morphology of
megakaryocytes
 Loose clusters

20. INFECTION/ LEUKEMOID
REACTION
Points FOR:
• PS:
 Leukocytosis
 Shift to left
 Toxic granulations
 Reactive lymphocytes
• Bone Marrow:
 Shift to left
 Toxic granulations
 Cytophagocytosis
 Increased megakaryocytes
 BM iron increased
Points AGAINST:
• Platelet count – variable
• Absence of fever/sepsis

21. APML/AML
Points FOR:
• Clinical presentation
• Leukocytosis
• Morphological
• Blasts, promyelocyts along
with other myeloid
precursors seen in PS
Points AGAINST:
• Age of presentation
• Hepatosplenomegaly of
various degree
• Blasts >20% of bone marrow
non-erythroid cells
• Suppression of erythroid and
megakaryocytic series

22. ALL
Points FOR:
• Age
• Clinical presentation
Points AGAINST:
• No Hepatosplenomegaly
• No Lymphadenopathy
• PS: Pancytopenia
• BM: Suppression of erythroid
megakaryocytic and myeloid
series
• Blasts >20% of bone marrow
non-erythroid cells
• Morphology of blast cells
L1 L2 L3

23. LYMPHOBLASTS VS MYELOBLASTS
LYMPHOBLAST MYELOBLAST
MORPHO-
LOGY
CYTO-
CHEMISTRY
PAS + (block)
Acid phosphatse + (T-cell)
PAS –
diffuse fine +ve in
M6,M7, M3*
MPO, Sudan Black, NSE +
I MMUNO-
PHENOTYPIN
G
B-cell - Strong CD19 and atleast 1 of the
following strongly expressed: CD79a,
cyCD22, CD10
T-cell - Cytoplamic CD3 or Surface CD3
MPO or
Monocytic differentiation (at least 2 of
the following NSE,
CD11C, CD14, CD64)
Only immunophenotyping permits a positive diagnosis of ALL

24. HEMATOGONES
• BM B-lymphocyte
precursors.
• Present in neonates, young
children , infection, post BM
transplant
• Diagnostic confusion with
ALL
• Immunophenotyping

25. MYELODYSPLASTIC SYNDROME
Points FOR:
• Bicytopenia
• Blasts ≥ 5%
Points AGAINST:
• Age
• PS: evidence of dysplasia
• BM: evidence of
dysplasia in >10% of
erythroid, granulocyte
precursors and
megakaryocytes

26. IMPRESSION
Peripheral smear along with bone marrow was
suggestive of -
IDIOPATHIC THROMBOCYTOPENIC PURPURA
with evidence of INFECTION

27. FURTHER INVESTIGATION
• NAP score
• Cytochemistry
• Immunophenotyping
• Cytogenetics
• Molecular genetics

28. SUMMARY
• Not every bleeding is APML
• Bleeding complaints
 Age,
 Family history
 Site of bleeding
 Preceding infection
 Lymphadenopathy and organomegaly
 Careful examination of PS
 BM Examination if indicated