HISTORY: This is a 7-year-old girl with clinical history of fever for 3 months. She was given a course of Cifrofloxacin as a treatment for Typhoid Fever, and a course of antimalarials (Chloroquin/Primaquin). At the present time she has pancytopenia (previous blood results unknown). Liver and Spleen were not palpable. Bone tenderness +/-.

CBC:
Hemoglobin: 4.8 gm/dl
Total white cell count: 2400/cmm
Diff Count:
PMN: 30%
Lymph: 66%
Mono: 2%
Atypical Cells: 2%
Platelets: 28,000/cmm.

She received one unit of whole blood transfusion.

Bone Marrow Aspiration done from Iliac Crest.
Cellularity: No Comment, as no particles aspirated.
Erythropoiesis: Predominantly Normoblastic.
Megakaryocytes: None seen in the smears (inadequate aspirate).
ME Ratio: 25.0:1

Images presented here (7) are from the BM aspirate and at 100x immersion oil.

What's your diagnosis?

Please reply to Dr. M.K. Baruah, MDRC, Dibrugarh at mkbaruah@pathoindia.com before June 17th, 2001.

ALL-L3: 14
Burkitt's Lymphoma: 3
AML M0/M1: 3
ALL-L2: 2

DISCUSSION:

Initially I had to debate whether I was dealing with a case of Aleukaemic All(L3) or Drug Induced Aplasia. But in this case the typical morphology with high NC ratio was diagnostic.

I also sent the case to the Armed Forces Institute of Pathology (AFIP) Washington for their opinion. This is their report:

"Increased abnormal blasts present morphologically compatiblible with leukaemia/lymphoma (FAB L3).There are increased numbers of Blasts with prominent cytoplasmic vacuolation compatible with Burkitt's Leukaemia/Lymphoma (FAB-L3) but we would need immunophenotypic and/or genotypic findings to confirm this impression. The differential includes Burkitts Leukaemia/Lymphoma, Acute lymphoblastic leukaemia with vacuolated FAB L2 Blasts, Acute myelogenous Leukaemia, particularly acute monoblastic leukaemia, and large cell lymphoma."