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A Curious Case of Morphologically Deceptive Pediatric B-Lymphoblastic Leukemia with Granular "Blebbed" Blasts and
Sunita Sharma1, Kavita Gaur1, Tatton Perme1
1Department of Pathology, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, Shaheed Bhagat Singh Marg, New Delhi, Delhi, India.
Insights
This is the first reported case of pediatric B-cell acute lymphoblastic leukemia (B-ALL) with blasts exhibiting both cytoplasmic granulation and blebbing. This unique morphology was observed in a 7-year-old boy diagnosed with B-ALL.
Area of Science:
- Hematology
- Pediatric Oncology
- Cell Biology
Background:
- B-cell acute lymphoblastic leukemia (B-ALL) exhibits diverse blast morphologies.
- Cytoplasmic granules and blebs are known lymphoblast features, but rarely occur simultaneously.
- Understanding blast morphology aids in B-ALL diagnosis and prognosis.
Observation:
- A 7-year-old boy presented with symptoms including fever, abdominal distension, and hepatosplenomegaly.
- Peripheral blood smear revealed 21% blasts with heterogeneous sizes, displaying both cytoplasmic granulation and blebbing.
- Bone marrow analysis confirmed B-ALL with specific immunophenotypic markers (CD10, CD19, HLA-DR) and atypical large cells resembling diffuse large B-cell lymphoma.
Findings:
- This case represents the first documented instance of pediatric B-ALL with granular, blebbed lymphoblasts.
- Immunohistochemistry confirmed expression of B-cell markers (PAX5, CD19, CD20) and bcl-2 in the atypical cells.
- The patient responded well to standard induction therapy, with no detectable blasts post-treatment.
Implications:
- The presence of granular and blebbed blasts in pediatric B-ALL may represent a distinct morphological subtype.
- Further research is needed to determine the clinical significance and prognostic value of this unique blast morphology.
- This finding expands the spectrum of morphological variations observed in B-ALL, aiding in differential diagnosis.
Abstract:
Background: B-cell acute lymphoblastic leukemia is known for heterogeneous blast morphology. Cytoplasmic granules and blebs have both been described, but not together, in lymphoblasts. Case presentation: A 7-year-old boy presented with fever, abdominal distension for 3 weeks, with hepatosplenomegaly. Investigations revealed pancytopenia, peripheral smear showing 21% blasts of varying size, displaying cytoplasmic blebbing and granulation. Marrow aspirate was hemodilute, 10% cells showed dim to moderate expression of CD45, CD10, CD19, HLA-DR confirming B-ALL. Megakaryocytic markers (CD41, CD61) were negative. Marrow biopsy showed a focus of large atypical cells displaying increased nuclear-cytoplasmic ratio, vesicular nuclear chromatin and macronucleoli, reminiscent of diffuse large B-cell lymphoma, cells strongly expressing PAX5, CD19, CD20, and bcl-2.The child was put on standard induction therapy. No blasts were detected in subsequent peripheral smears. Conclusion: To the best of our knowledge, this is the first case of pediatric B-ALL displaying granular "blebbed" blasts.
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