#00060526

35 years female presented with History of fever for 25 days and steroid intake. Her peripheral blood counts showed:

HB:              8.1 G/DL

HCT:             24.2 %

MCV:             101.3 FL

MCH:             33.9 PG

WBC'S:           10.9 x 10E9/L

ANC:             4.9 x 10E9/L

PLATELETS:       37 x 10E9/L

Peripheral blood film showed 25% blast cells bone marrow examination was performed which showed hypercellular marrow showing infiltration with blast cells which constitute about 44% of total nucleated non-erythroid cell population. These blast cells were medium in size, having low nuclear to cytoplasmic ratio, fine nuclear chromatin, prominent nucleoli and abundant granular cytoplasm. Auer rod seen. 20% blast cells exhibit hand mirror appearance. Cytochemistry was performed which showed positivity of Sudan black B in blast cells. Immunophenotyping by flowcytometry was done which revealed positivity of myeloid markers i.e, CD13,CD33, CD117, CD34 and cMPO along with HLA-DR and CD45. Aberrant expression of CD19 is also noted.Results of Bone marrow cytogenetic studies showed:46,XX,add(6)(q27),add(7)(q36),t(8;21)(q22;q22)[17].

NPM1 mutation not detected. FLT3-ITD and D835 mutations were detected. She was started on Induction chemotherapy of daunorubicin and cytarabine. Her Day 14 & day 28 post chemotherapy marrow was in remission and complete cytogenetic response was achieved. She remained well until febuary 2016 then on 11th march 2016 she had high grade fever, CBC shows 90% blast cells and again  15% of these blast cells exhibited hand mirror appearance.