Acute promyelocytic leukemia presenting as recurrent venous and arterial thrombotic events: a case report and review of the literature

Figures & data

Table 1. Complete blood count with differential throughout clinical course

Test	1^st Admission (5/10/20)	2^nd Admission (8/1/20)	3^rd Admission (8/15/20)	Reference Range
WBC Count	4.40	2.82	3.58	4.80–10.80 K/μL
RBC Count	5.12	4.81	4.65	4.70–6.10 M/μL
Hemoglobin	15.8	15.1	14.3	42.0–52.0%
MCV	86.5	89.4	86.9	80.0–94.0 fL
Platelets	300	352	194	130–400 K/μL
Neutrophils	2.58	1.17	2.55	1.40–6.50 K/μL
Lymphocytes	1.30	1.22	0.78	1.20–3.40 K/μL
Monocytes	0.27	0.17	0.18	0.10–0.60 K/μL
Eosinophils	0.22	0.07	0.05	0.00–0.70 K/μL
Basophils	0.03	0.08	0.01	0.00–0.20 K/μL

Figure 1. Computer tomography angiography of the chest demonstrating bilateral segmental lower lobe pulmonary embolism

Table 2. Hypercoagulable workup

Methylenetetrahydrofolate reductase (MTHFR) gene	Heterozygous for the C677T mutation
Factor V Leiden gene	Absence
Prothrombin gene	Absence
Beta-2 glycoprotein antibodies	Negative
Anti-cardiolipin antibodies	Negative
Protein C Functional Assay	135% (Normal: 65–129%)
Protein S Free Activity Assay	117% (Normal: 70–150%)
Antithrombin III Assay	144% (Normal: 85–135%)
Silica Clotting time	Normal
Dilute Russell’s Viper Venom time	Normal

Figure 2. Computer tomography abdomen revealing wedge-shaped defects of the spleen consistent with infarcts

Figure 3. a.Bone marrow aspirate smear showing promyelocytes with ovoid to monocytoid nuclei, abundant cytoplasm with numerous pink, red or purple granules that obscure the nuclear outline. the cells contain numerous intertwining auer rods (arrows). b. The bone marrow biopsy showing hypercellularity with aggregates of promyelocytes (x200). c. High power image showing promyelocytes with relatively abundant cytoplasm and convoluted nuclei that are often eccentrically located (x400)

Table 3. Review of the literature of patients with acute promyelocytic leukemia (APL) presenting with thrombosis

Organ Involved	Date	Age (years)	WBC	Platelets
MI	1980[^26] 1986[^27] 1993[^28] 2006[^29] 2007[^30] 2011[^31] 2012[^32] 2013[^33] 2015[^34]	46 NA 38 41 54 29 51 15 33	NA NA 1.7 X 10^9/l 5.4 X 10^9/l 0.6 X 10^9/l NA 3.1 X 10^9/l 3.9 X 10^9/l 3.9 X 10^9/l	NA NA NA 60 X 10^9/l 112 X 10^9/l NA 85 X 10^9/l 27 X 10^9/l NA
Acute limb ischemia	1981[^35] 1992[^36] 1998[^37] 1999[^38] 2003[^39] 2003[^40] 2009[^41] 2016[^42] 2020[^43]	25 10 16 16 47 39 51 75 71	NA 31.7 X 10^9/l NA 2.9 X 10^9/l 4.4 X 10^9/l 19.2 X 10^9/l 8.4 X 10^9/l 43.5 X 10^9/l 4.6 X 10^9/l	NA NA NA 62 X 10^9/l 105 X 10^9/l 40 X 10^9/l 90 X 10^9/l 65 X 10^9/l 46 X 10^9/l
Ischemic stroke	2010[^44] 2013[^45] 2015^6 2016[^46]	49 23 38 10	6.9 X 10^9/l 85.0 X 10^9/l 8.6 X 10^9/l 2.4 X 10^9/l	151 X 10^9/l 45 X 10^9/l 47 X 10^9/l 30 X 10^9/l
DVT, acute limb ischemia	2014[^47]	52	NA	NA
DVT, PE	2015[^48]	48	14.8 X 10^9/l	NA
DVT, LV thrombus	2020[^49]	20	1.6 X 10^9/l	334 X 10^9/l
Hepatic vein thrombosis	2010[^50]	14	23.4 X 10^9/l	80 X 10^9/l
DVT, PE, ischemic stroke, splenic infarct, renal infarct	Our case	50	2.0 X 10^9/l	244 X 10^9/l

Legend: WBC, white blood count; MI, myocardial infarction; NA, not available; DVT, deep vein thrombosis; LV, left ventricle; PE, pulmonary embolism

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