SP14 | A VITAMIN DEFICIENCY MIMES AN ACUTE MYELOID LEUKEMIA

Sepsis, a dysregulated response to infection, is a life-threatening condition with high mortality and is associated with widespread organ, such as bone marrow, dysfunction. In addition, other conditions like vitamin deficiency or drug toxicity, may contribute to skew bone marrow features. A 67-year-old woman presented to emergency department with fever, diarrohea, severe hypotension and lethargy. Her medical history included psoriatic arthritis and bipolar psychiatric disorder in home therapy with Clotiapine, Olanzapine, Valproic acid and Methotrexate. Laboratory findings revealed severe pancytopenia: leukocyte count of 1.4 × 109/L, hemoglobin of 5.7g/dl, 110 MCV and platelets count of 4x103/dl. Procalcitonin was 35ng/ml. Extreme hypotension was observed: so patient was admitted to intensive care department to underwent to intravenous norepinephrine and empiric antibiotic therapy. Because of the pancytopenia a bone marrow aspirate had been perfomed. Meanwhile laboratory tests revealed a severe acid folic deficiency (<1.2 µg/L). The bone marrow was hypercellular with large-sized cells with high nuclear-cytoplasmic ratio (myeloid blast-like appearance) and left shifted myeloid lineage. Flow cytometry supported the hypothesis of Myelodisplastic Syndrome but no relevant increment of CD34+ cells had been shown. Due to persistent septic condition, the patient was treated according to the Surviving Sepsis guideline until a progressive improvement of vital signs. Folic acid was supplemented. Within nutrient supplementation and with the sepsis resolution, the blood count backed to normal: hemoglobin rised to 9.5g/dl, leukocyte counts reached 7.4x 109/L and platelets value was 274x103/ml. A new bone marrow aspiration was performed with no signs of dysplasia in the granulocytic and megakaryocytic cell lineages. We reported a rare case of “mimed” diagnosis of acute leukemia in the context of vitamin deficiency, sepsis and drug toxicity. Indeed there are several conditions that could modify the bone marrow features miming myelodysplastic syndromes or other malignant hemopathies. Vitamin B12 and folate deficiencies are well-known causes of megaloblastic anemia and a recognized cause of myelodysplastic marrow changes. While vitamins deficiency severe enough to cause MDS-like morphology is unusual in the developed countries, it should be taken into consideration when it is associated with other causes of cytopenia like sepsis or drugs. Also sepsis may contribute to bone marrow dysregulation. The bone marrow mounts a response to septic shock, aiming to maintain hematopoiesis and mobilize immune cells to combat the infection. One prominent alteration is the expansion of myeloid progenitor cells and a shift towards myelopoiesis, just like it has been observed in this case report.