Acute Promeylocytic Leukemia Presenting as Fatal Intracranial Bleeding in a Rural Setting

Abstract

Acute promyelocytic leukemia (APL) is a biologically and clinically distinct variant of acute myeloid leukemia (AML), and accounts for 5 to 20 percent of all AML cases. It is a highly curable hematological malignancy with targeted therapy. Patients usually present with symptoms of the complications, typically bleeding. Intracranial bleeding with APL is rarely seen at the presentation, but more common in relapsed cases. APL is a medical emergency with a high rate of early mortality, usually due to catastrophic bleeding if it is not treated timely. It is vital to start treatment once the diagnosis is suspected without waiting for definite diagnosis. We presented a 35-year-old foreign worker who presented with headache and blurring of vision for 5 days, associated with fever and multiple episodes of vomiting on the day of admission. Subsequently he developed status epilepticus and disseminated bleeding. He had raised leukocyte, low platelet, prolonged international normalized ratio and prolonged prothrombin time. His computed tomography (CT) brain revealed intracranial hemorrhage. He was intubated and was transfused one cycle of disseminated intravascular coagulation regime. He was referred to intensive care unit and neurosurgical team. Unfortunately, the patient passed away within 5 hours of hospitalization. His urgent peripheral blood film subsequently came back after he passed away and showed increased white blood cell with more than 90% of abnormal promyelocytes, Auer rods and Faggot cells, suggestive of APL. This case highlights the importance of high index of suspicion; the timely and urgent treatment, which is crucial and might prevent the catastrophic event.