CNS Relapse in Acute Promyelocytic Leukemia: A Rare Occurrence

Abstract

ABSTRACT: Acute Promyelocytic leukemia with central nervous system involvement is one of the rarest occurrences. A 25
year old lady, admitted at Shifa International Hospital Islamabad, with complaints of menorrhagia, bruises, petechiae, headache
and vomiting. Her laboratory investigation showed patient being in disseminated intravascular coagulation. Complete blood
counts and Bone marrow examination showed significant promyelocytes and blasts with flow cytometric analysis consistent
with acute promyelocytic leukemia (APL). PCR for PML-RAR? detected, CSF examination and its cytology revealed promyelocytes. CT scan of brain showed slight leptomeningeal enhancement. CNS involvement was diagnosed based on the appearance of APL blasts in cerebrospinal fluid (CSF). After treated with all-trans retinoic acid (ATRA), idarubicin, cytarabine and intrathecal methotrexate, she achieved morphological, molecular, and CNS remission. Patient was readmitted, 02 years later with complaints of headache, vomiting, right sided weakness and difficulty in speaking with suspicion of relapse. Lumber puncture was performed which showed many promyelocytes with Auer rods and diagnosis of CNS relapse of APL was made.