A 62-year-old woman underwent right monopulmonary transplantation in May 2011 for idiopathic pulmonary fibrosis.
At the third month, a cryptogenic pneumonia and bilateral pulmonary thromboembolism were diagnosed, so she received corticosteroids boluses and anticoagulation for 6 months, progressing satisfactorily.
The immunosuppressive regimen consisted of prednisone, azathioprine and tacrolimus.
In prophylaxis with cotrimoxazole, itraconazole and clarithromycin.
In subsequent controls only mild permanent anemia stood out, but with normal lung function and radiology.
Since July 2013, leucopenia was progressively attacked, so cotrimoxazole was suspended and controlled with blood count, which showed Hb 11g/dL, platelets of 400000/mm3, normal neutrophils.
Neutropenia secondary to drugs was thought, so azathioprine was discontinued.
It was also left with folic acid, vitamin B12 and given that the patient had an infectious condition and a greater decrease in neutrophils, a granulocyte colony stimulator was indicated.
However, the patient developed progressive pancit.
Control blood count at one week was: Hb 6.8 g/dL, leukocytes 500/mm3, neutrophils 100/mm3 and platelets 15,000/mm3, with some signs of dysplasia in neutrophils.
Myelogram showed 20% of myeloid blasts.
It was initially attributed to bone marrow recovery; however, in a control smear 2% blasts were found, so a new myelogram was performed.
This showed 35% of blasts of abundant cytoplasm, of monocytoid aspect.
The immunophenotypic study showed blasts of myeloid lineage, of which 5% corresponded to low CBF/SSC, low CD45, weak CD34, CD13, CD15 and CD19 moderate CD19 granulocytic CD13, CD13 CD19, CD19 and CD16, CD33 intermediate CD17 cells,
27 metaphases with G-banding were analyzed by cytogenetic analysis, 7 of them karyotyped, finding an abnormal hyperdiploid clon of 58~60 chromosomes, and 15 chromosomes of 6, and 10 chromosomes.
An extra chromosome 1 with deletion of arm q, and a chromosome 5 with an interstitial deletion of arm q in duplicate are also found.
A karyotype composed by cell heterogeneity was elaborated: 58~60,XX,+X,+del(1)(q10),del(5)(?q13q33),+del(5)(?q13q33),+6,21,+
Myelomonocytic leukemia with granulocytic dysplasia was concluded.
Complex alterations along with observed chromosome 5 alterations suggested therapy-related acute leukemia.
The patient was admitted with respiratory failure secondary to intrahospital pneumonia of rapid evolution and finally died within a few days.
