Patients with leukemia experience profound immunosuppression both from their underlying disease as well as chemotherapeutic treatment. Little is known about the prevalence and clinical presentation of nontuberculous mycobacteria (NTM) in this patient population. We identified six cases of NTM infection from 29,743 leukemia patients who had acid-fast bacilli (AFB) cultures. Four cases had bloodstream infections and five had disseminated disease, including one who presented with an unusual case of diffuse cellulitis/myositis. All patients were lymphopenic at time of diagnosis, and two patients ultimately died from their NTM infection. NTM infections are a rare, but potentially life-threatening infection in patients with leukemia. Sending AFB cultures early is important to direct appropriate antimicrobial therapy and allow for future leukemia-directed therapy.

Methemoglobinemia is a potentially life-threatening, rare condition in which the oxygen-carrying capacity of hemoglobin is diminished. We present the case of a 3-year-old boy treated for T-cell acute lymphoblastic leukemia (T-ALL) who developed methemoglobinemia (MetHb 57.1%) as a side effect of ifosfamide administration. Due to his critical condition, the patient was transferred to the intensive care unit (ICU). The therapy included methylene blue administration, an exchange transfusion, catecholamine infusion, and steroids. Improving the general condition allowed for continuing chemotherapy without ifosfamide and completion of the HR2 block. Vigilance for methemoglobinemia as a very rare side effect should be widespread when using ifosfamide in the treatment protocols.

UNASSIGNED: Infant leukemia is a rare form of acute leukemia diagnosed prior to the age of 1 and is characterized by an extremely poor prognosis due to its dismal response to current therapeutic approaches. It comprises about 4% of all childhood cases of acute lymphoblastic leukemia (ALL). Isolated initial cutaneous involvement in ALL is uncommon, and even more so in infant ALL.
UNASSIGNED: Here, we present the case of a 2-month-old healthy-appearing infant, initially presenting with a single scalp nodule and subsequently diagnosed with an infant ALL. The leukemia was characterized by the most immature B-lineage immunophenotype [pro-B ALL/B-I, according to the European Group for the Immunological Characterization of Leukaemias (EGIL) classification] and chromosomal translocation t(9;11)(p22;q23), resulting in fusion gene KMTLA2::MLLT3, which is considered a negative prognostic factor. The patient underwent hematopoietic stem cell transplantation and is still in remission.
UNASSIGNED: This case is peculiar because of the rare occurrence of isolated initial cutaneous involvement in ALL. Despite the healthy appearance of the patient, every suspicious symptom suggestive of malignancies should be further investigated to anticipate the diagnosis and start treatment early.

The coronavirus disease 2019 (COVID-19) pandemic is a universal emergency public health issue. A large proportion of the world\'s population has had several spike antigen exposures to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and/or COVID-19 vaccinations in a relatively short-term period. Although sporadic hematopoietic adverse events after COVID-19 vaccine inoculation were reported, there is currently no sufficient evidence correlating anti-spike protein immune responses and hematopoietic adverse events of vaccinations. We reported the first case of Ph-positive B-cell acute lymphoblastic leukemia (ALL) occurring after a bivalent mRNA COVID-19 vaccine inoculation. The otherwise healthy 43-year-old female patient had a total of six spike antigen exposures in the past 1.5 years. Informative pre-vaccine tests and bone marrow study results were provided. Although the causal relationship between bivalent vaccinations and the subsequent development of Ph-positive B-cell ALL cannot be determined in the case report, we propose that anti-spike protein immune responses could be a trigger for leukemia. Clinicians must investigate the hematopoietic adverse events closely after COVID-19 vaccinations. Further pre-clinical studies to investigate the safety of bivalent mRNA COVID-19 vaccine are required.

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Pegylated (PEG)-asparaginase is an established treatment for acute lymphoblastic leukemias that exhibits an antitumor effect by depleting asparagine, an amino acid essential for leukemia cell protein synthesis. Pancreatitis with hypertriglyceridemia is a well-established toxidrome associated with PEG-asparaginase. However, impaired pancreatic synthetic function and hormone release have rarely been reported as a result of PEG-asparaginase pancreatitis. In this report, we present a 22-year-old woman recently diagnosed with T-acute lymphoblastic leukemia (T-ALL), who presented to the hospital with progressive weakness, confusion, blurry vision, hallucinations, and abdominal pain after induction treatment with daunorubicin, vincristine, PEG-asparaginase, and dexamethasone following the AYA protocol. She was found to have hypertriglyceridemia, acute pancreatitis, and hyperosmolar hyperglycemic syndrome. While pancreatitis and hypertriglyceridemia are commonly reported side effects of PEG-asparaginase, HHS related to these conditions has been sparsely reported. Providers should maintain awareness of this association and consider routine serial glucose monitoring of patients receiving PEG-asparaginase.

Acute lymphoblastic leukemia (ALL) is a hematologic cancer that begins in the bone marrow and results in an overproduction of lymphocytes. It can present as palpable purpura, which is also seen in many other pathologies, including vasculitides such as IgA vasculitis. We present a case of a 52-year-old male who presented to our hospital from an outside facility specifically for plasma exchange for treating a previously diagnosed IgA vasculitis. After being admitted for further evaluation, it was noted that the patient had a diffuse petechial non-blanching purpuric rash bilaterally covering the lower extremities, trunk, upper extremities, and tongue. The patient was also noted to have severe pancytopenia. Fluorescence in situ hybridization (FISH) demonstrated the presence of t(9:22), indicating Philadelphia chromosome rearrangement. The patient was diagnosed with ALL. The patient underwent induction chemotherapy and was continued on hyper-CVAD protocol with intrathecal chemotherapy. The patient appeared to respond well to treatment and is currently undergoing subsequent intermittent chemotherapy. In this case, the diagnosis of B-cell ALL (B-ALL) blast crisis was pivotal in providing the correct therapy to this patient, and the case demonstrated that even rare presentations of B-ALL in this population with rare mutations responds avidly to tyrosine kinase inhibitors.

UNASSIGNED: To explore the functions of the polymorphisms in 5-methylcytosine (m5C) modification-related coding genes on the susceptibility of pediatric acute lymphoblastic leukemia (ALL).
UNASSIGNED: Case-control study and multinomial logistic regression analysis were performed to construct models to evaluate the susceptibility of pediatric ALL. The relationship between five functional SNPs in m5C modification-coding genes and pediatric ALL risk was analyzed. Genotyping of 808 cases and 1,340 healthy samples from South China was identified using a TaqMan assay; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to estimate the relationship between the five selected SNPs and pediatric ALL susceptibility.
UNASSIGNED: Among the five analyzed SNPs, NOL1 rs3764909 and NSUN4 rs10252 variants significantly increased the susceptibility of pediatric ALL, while NSUN3 rs7653521, NSUN5 rs1880948, and NSUN6 rs3740102 variants were not associated with the risk of ALL. Stratification analyses demonstrated that NOL1 rs3764909 C>A exhibited a significant association with increased pediatric ALL risk in subgroups of common B ALL, pre-B ALL, T-cell ALL, low and middle risk, other gene fusion types, non-gene fusion, hypodiploid, normal diploid, primitive lymphocytes in marrow < 5% on week 12, and minimal residual disease (MRD) <0.01% on week 12 after induced therapy; NSUN4 rs10252 G>A was related to increased risk of ALL children in subgroups of age ≥ 120 months, normal white blood cell (WBC) number, middle risk, non-gene fusion, MRD ≥ 0.01 on days 15-19, and primitive lymphocytes in marrow < 5% on day 33 after induced therapy. Compared with the reference haplotype CAGTA, children who harbored haplotypes CCGTG and ACATA were remarkably related to increased ALL susceptibility. rs3764909 and rs10252 varieties of alleles were not associated with MRD levels after the selected chemotherapeutics.
UNASSIGNED: In conclusion, NOL1 rs3764909 and NSUN4 rs10252 variants were enhanced by pediatric ALL risk and were suggested to be potential biomarkers for pediatric ALL.

B-acute lymphoblastic leukemia (B-ALL) is commonly encountered in clinical practice. Patients present with increased percentage of lymphoblasts in bone marrow and/or peripheral blood. Immunophenotypic study by flow cytometry or immunohistochemistry is essential to establish the diagnosis. Paired box-5 (PAX5) is a B cell lineage protein and terminal deoxynucleotidyl transferase (TDT) is an immature marker, both of which are routinely tested in the pathologic workup of acute leukemia. In this report, we describe a case of B-ALL in a 37-year-old woman in which both PAX5 and TDT were negative. Next-generation sequencing test detected mutations in DNA methyltransferase 3 α and Fms related receptor tyrosine kinase 3 genes, which are frequently mutated in acute myeloid leukemia rather than B-ALL. The constellation of these rare findings in a single case signifies the importance of examining a wide panel of markers when the diagnosis of ALL is suspected.

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is an aggressive hematological malignancy with a rare incidence with poor outcome. Usually, it presents by skin infiltration then dissemination and only 10% may present first by bone marrow (BM) infiltration. It has overlapping features with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) clinically and pathologically, and there are many diseases to be differentially diagnosed from them. There is no consensus for treating BPDCN, but there are some novel therapies that have emerged in the field for treating this group of patients. A case report of 47-year-old diabetic male, presented to the hematology unit of Oncology Center of Mansoura University with a large, elevated scalp mass on the anterior part near the forehead with overlying pressure necrosis of the skin and face edema and with similar lesions on the back. There were enlarged cervical and inguinal lymph nodes. Skin biopsy revealed infiltration by monomorphous medium-sized blastoid cells, with fine chromatin and scanty cytoplasm, pannicular extension, and no detected epidermotropism. Immunohistochemistry revealed diffuse membranous immunoreactivity for CD4, CD56, and BCL2. Ki-67 proliferation index was about 90%. CD117, MPO, CD34, CD20, CD5, CD3, ALK, CD79a, and CD30 showed negative immunoreactivity in the tumor cells. BM examination showed infiltration by 80% large blastoid cells with basophilic cytoplasm and fine chromatin. Multi-color-flowcytometry (MCF) revealed low CD45 expression (located in the blast pocket) and positive CD123, a spectrum of CD56 (moderate to negative), dim CD4, CD43, partial dim CD33, CD38, CD81, and partial CD36 (predominantly negative), and was negative for the rest of the panel. The patient received Hyper-CVAD protocol (cyclophosphamide, vincristine sulfate, doxorubicin hydrochloride, and dexamethasone) and skin lesions showed marvelous response after 1st cycle of chemotherapy. BM and FDG -PET/CT evaluation was free from abnormal cell infiltration. Now he is completing his chemotherapy and planned for allogenic stem cell transplantation (SCT). The diagnosis and management of such cases are challenging at all levels from the beginning of the disease, through the steps of diagnosis and finally in choosing the appropriate treatment protocol. We recommend ALL-based chemotherapy protocols especially Hyper-CVAD then allogenic SCT for better response and overall survival.