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A 37-year-old office worker was referred to our hospital with severe weakness, malaise, headache and altered mental status. He was mildly febrile (37.5°C) with reported episodes of agitation. A blood count revealed 709 720 white blood cells (WBC)/μl with 33 000 platelets/μl. The clinical, imaging and laboratory workup led to a diagnosis of acute lymphoblastic leukaemia (ALL) with MLL-AF4 genotype. A gradient recalled echo T2*-weighted MRI showed diffuse cerebral petechial haemorrhages (figure 1).1 Several microbleeds showed a slight hyperintense ring, suggesting haemosiderin deposits. No surrounding oedema was detected.
Lumbar puncture showed clear, colourless CSF with no red cells and 15 white cells; protein concentration was 56 mg/dl. Cytofluorimetric analysis of the CSF demonstrated SSC low/CD45 high cells, which were 48% of the total CD19+/DR+WBC. The patient underwent treatment with daunorubicin, vincristine, prednisone and intrathecal methotrexate which led to a marked reduction in blast cells and a significant increase in platelets (ie, 11 610 WBC/μl and 202 000 platelets/μl). Neurological symptoms gradually improved and a follow-up MRI showed no new bleeds. An extensive laboratory and imaging workup ruled out common causes of cerebral bleeding (eg, cerebral amyloid angiopathy).
Although granulocytic sarcoma (chloroma), as a brain collection of acute leukaemic cells,2 may rarely cause haemorrhage,3 microbleeds occur in ALL when a high number of WBC, inducing hyperviscosity and increased capillary pressure, associate with low platelets.4 The soft brain tissue represents a favourable environment for petechial haemorrhages.
Contributors RS contributed to the diagnosis and MRI interpretation, and drafted the manuscript. VLB contributed to the MRI interpretation and revised the manuscript.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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