case_images: PMC6276408_01
case_images: Peripheral blood leukocytosis with left shift and blasts (arrows) (a) Wright stain, x400. Hypercellular bone marrow with myeloid and megakaryocytic hyperplasia; blasts < 5% (b) H&E, x100. Cluster of atypical megakaryocytes in bone marrow (c) H&E, x400. Abnormal bone marrow karyotype: 46,XY,t(9;22)(q34;q11.2)[19]/47,idem,+8 [1] (d).
case_images: CRIONM2018-7276128.001.jpg
case_images: PMC6276408_01_CRIONM2018-7276128.001.jpg
case_images: fig1
case_images: The bone marrow biopsy showed hypercellular marrow with striking granulocytic and megakaryocytic hyperplasia with atypical megakaryocytes and moderate reticulin fibrosis (Figure 1(a)-1(c)). Fluorescent in situ hybridization (FISH) analysis and karyotyping (Figure 1(d)) confirmed presence of BCR-ABL1 translocation.
case_images: Cervical lymph node with diffuse effacement by blasts (a) H&E, x400. Immunohistochemistry, anti-CD3 (b) x400. Flow cytometry: neoplastic cells are positive for CD7 and negative for surface CD3 (c-A), positive for cytoplasmic CD3 and negative for MPO (c-B), positive for CD33 (c-C), and partially positive for TdT (c-D).
case_images: CRIONM2018-7276128.002.jpg
case_images: PMC6276408_01_CRIONM2018-7276128.002.jpg
case_images: fig2
case_images: This showed diffuse nodal effacement by blasts that were positive for CD3 and negative for CD20, CD34, and myeloperoxidase by immunostaining (Figures 2(a) and 2(b)). TdT, and, to a lesser extent, CD1a, while lacking sCD3, CD4, CD8, CD5, and defining markers for myeloid, monocytic, and B-lymphoid lineage (MPO-, CD14-, CD64-, CD11b-, CD19-, and CD20-) (Figure 2(c)). The blasts were positive for BCR-ABL1 by FISH and karyotyping (Figures 3(a) and 3(b)), with additional chromosomal abnormalities indicating clonal evolution of CML with T-cell blast crisis. T-cell gene rearrangement on the lymph node was negative; however, that did not rule out T-cell blast crisis.
case_images: Cervical lymph node: BCR/ABL1 detected by FISH (a). Abnormal lymph node karyotype: 51-53,XY,+8,+8,t(9;22)(34;q11.2),+15,+19,+21,+21,+der(22)t(9;22)[cp20] (b).
case_images: CRIONM2018-7276128.003.jpg
case_images: PMC6276408_01_CRIONM2018-7276128.003.jpg
case_images: fig3
case_images: TdT, and, to a lesser extent, CD1a, while lacking sCD3, CD4, CD8, CD5, and defining markers for myeloid, monocytic, and B-lymphoid lineage (MPO-, CD14-, CD64-, CD11b-, CD19-, and CD20-) (Figure 2(c)). The blasts were positive for BCR-ABL1 by FISH and karyotyping (Figures 3(a) and 3(b)), with additional chromosomal abnormalities indicating clonal evolution of CML with T-cell blast crisis. T-cell gene rearrangement on the lymph node was negative; however, that did not rule out T-cell blast crisis.