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Case Reports

Indian Pediatrics 2003; 40:155-158 

Down Syndrome with Transient Myeloid Leukemia and Urological Abnormality

Amar A. Shah
Ashish A. Mehta
Mahendra Desai
Anirudh V. Shah

From the Departments of Pediatrics and Pediatric Surgery, K.M. School of Postgraduate Medicine & Research, N.H.L. Municipal Medical College, V.S. Hospital, Ahmedabad, India

Correspondence to: Dr. A. V. Shah, "Anicare", 13, Shantisadan Society, Nr. Parimal Garden, Nr. Doctor House, Ellisbridge, Ahmedabad 380 006, India.
E-mail: anirudhshah@icenet

Manuscript received: April 1, 2002; Initial review completed: May 10, 2002; Revision accepted: August 27, 2002.

Among the various anomalies associated with Down syndrome, leukemia is quite common. The variant ‘transient myeloid leukemia’ is seen almost exclusively in the Down syndrome patients. On the other hand, urological anomalies are infrequently found both in the Down syndrome and Leukemia patients. We report a case who had the rare combination of a urological aomaly along with Down syndrome and transient myeloid leukemia.

Key words: Down syndrome, transient myeloid leukemia, urological anomaly.

 

Congenital leukemia is a rare malignancy diagnosed in the first month of life. One of the common associations with congenital leukemia is Down syndrome. We report a rare trio of Down syndrome, transient myeloid leukemia and a urological abnormality in the form of pelviureteric junction obstruction.

Case Report

A one-month-old boy was referred to us with a diagnosis of pelviureteric junction obstruction. The child was a full term delivery; the maternal age was 28 years. The child had an elder brother who was normal. The mother had a normal antenatal period and did not receive any medications throughout pregnancy. The neonate had features of Down syndrome (low set ears, protruded tongue, flattened nasal bridge, mongoloid slant of eyes), and a left renal lump. There was no hepatosplenomegaly, lymphadenopathy or any cutaneous lesions over the body. All the other systems were normal.

Hematological investigations showed hemoglobin level of 10 g/dL, a total leukocyte count of 40,200/ cumm and platelet count of 40,000/cumm. The peripheral blood smear showed normocytic normochromic red cells. There was marked leukocytosis with a shift to the left, with 27% polymorphs, 23% lymphocytes, 41% blast cells, 7% myelocytes and 2% metamyelocytes. The ratio of immature neutrophils to total cells was normal (<0.2). The blood urea level was 35 mg/dL and creatinine 0.8 mg/dL; electrolytes were within normal limits. CRP was negative and the blood gas analysis was normal. The blood culture was sterile. Bone marrow examination showed predominant marrow cells, more than 85% of which were of granulocytic origin; 43% were blasts, morphologically myelo-blasts. Myelocytes and polymorphs cons-tituted 25% and 24% cells respectively. Occasional blast cells with Auer rod were also noted. Cytochemistry was positive for Sudan Black and PAS was negative. Erythropoiesis was markedly depleted and megakaryocytes were scanty. The diagnosis of left pelvi-ureteric junction obstruction was confirmed on ultrasound, intravenous pyelography and DTPA renal scan. Chromosomal study showed 47 XY, +21 Karyotype. The lymphocyte culture showed free trisomy 21 with normal sex chromosomes. There was no evidence of fragility or translocation.

The child received antibiotic prophylaxis (amoxicillin 5 mg/kg/day). Follow up was done for the kidney with serial ultrasound examinations and DTPA scans every three-monthly. Serial hematological monitoring was done monthly. During the repeat hematological studies, the number of blast cells decreased and the polymorphs and lymphocytes increased. At the age of 6 months, the hematological investigations were normal with 1% blasts on peripheral smear. Bone marrow examination showed less than 4% blast cells. The child had pyelo-plasty for pelviureteric junction obstruction at the age of nine months. The postoperative period was uneventful. The child was well and on regular follow up nine months after the surgery. A repeat hematological examination six months after the surgery was also normal.

Discussion

Leukemia in the newborn period has been associated with Down syndrome(1,2), Turner syndrome(3), mosaic monosomy 7(4) and trisomy 9(5). Studies have shown an estimated risk of leukemia 14-30 times in patients with Down syndrome(6).

Congenital leukemia is a rare malignancy diagnosed before four weeks of age(7). The criteria, which must be fulfilled for diagnosis are (i) proliferation of immature leukemia cells; (ii) infiltration of these cells into non hemopoietic tissue; (iii) absence of other disease processes such as congenital hypoxia, erythroblastosis fetalis, congenital syphilis that can cause a leukemoid or leukoerythro-blastic reaction, mimicking congenital leukemia(8).

Newborn infants with Down syndrome frequently present with a disorder character-ized by the appearance of primitive cells in the peripheral blood. These cells have been characterized with a variety of ancillary techniques as megakaryoblasts. Many different names have been used to describe this disorder, the most common of which is transient myeloproliferative disorder. Although the hematological picture is indistinguishable from leukemia, it has been difficult to accept this as a true leukemia because in most instances, the disease disappears spontaneously. However, there is evidence that the disorder is truly leukemia, and therefore it is referred to as transient leukemia. In view of the myeloproliferative disorders or ineffective regulation of granulopoesis resulting in this disease, it has also been called transient abnormal myelopoesis(8).

In a study at the Hospital for Sick Children, following conclusions were drawn: (i) Approximately 20% of leukemia (excluding transient leukemia) in Down syndrome is acute megakaryoblastic leukemia; (ii) Approximately 20% of all leukemia in Down syndrome is transient leukemia; (iii) Transient leukemia in Down syndrome is acute megakaryoblastic leukemia (M7); (iv) Recurrence of acute megakaryo-blastic leukemia occurs in 20-25% of cases of transient leukemia; (v) The incidence of acute megakaryoblastic leukemia in Down syndrome is estimated to be 400 times that in normal children(9).

The basis of this association has been hypothesized to be influenced by the mechanism of the extra chromosome(6). Serial cytogenetic studies using banding techniques at various stages during the course of the disease (preleukemia, leukemia, remission and relapse) showed several chromosomal abnormalities (unbalanced translocation between chromosomes 1 and 4 leading to trisomy 1q, trisomy 7q, monosomy 7p, and a reciprocal translocation between chromosomes 10 and 16(10).

Sometimes in Down syndrome one cannot clinicaly and hematologically differentiate between acute leukemia and transient myelo-proliferative disorder. Judicious supportive care and clinical monitoring for 3-6 weeks is necessary. If clinical or hematological deterioration continues, the possibility of transient myeloproliferative disorder is ruled out and appropriate chemotherapy should be instituted(3,8).

No evidence of hepatosplenomegaly was noted in our patient. Cutaneous manifesta-tions which contain infiltrates of leukemic cells were also absent. Serial hematological investigations showed a gradual decline in the number of blasts, which reduced to almost 25% by the end of the third month.

Transient leukemia is not associated with any abnormal signs or symptoms. Our patient however, had an associated pelviureteric junction obstruction, the association of which is very rare, both with Down syndrome and transient myeloid leukemia. Malformations like ventricular septal defect, duodenal atresia, cleft lip and palate are known to be commonly associated with Down syndrome(11). The only urological anomaly consistently related to this disease is posterior urethral valves(12,13). Extensive review of literature does not show any reports of the presence of this rare trio of Down syndrome, urogenital and transient myeloid leukemia. The long-term prognosis of transient leukemia is good. In majority of the cases, the disease disappears and there are no recurrences or long-term side effects. However, acute mekaryoblastic leukemia may develop within the first 4 years of life, and this makes a regular follow up mandatory.

Contributors: AAS carried out the clinical work up and drafted the manuscript. AAM was the pediatrician incharge of the patient and helped in drafting the paper. MD helped in the hematological description and interpretation. AVS was the consultant incharge, supervised the drafting of the paper and will act as the guarantor of the manuscript.

Funding: None.

Competing interests: None stated.

 

 References


1. Rosner F, Lee SL. Down syndrome and acute leukemia: myeloblastic or lymphoblastic? Report of forty- three cases and review of the literature. Am J Med 1972; 53: 203-218.

2. Weinstein HJ: Congenital leukemia and the neonatal myeloproliferative disorders asso-ciated with Down syndrome. Clin Hematol 1978; 71: 47-51.

3. Sallan SE, Weinstein HJ. Childhood acute leukemia. In: Nathan DG, Oski FA, eds. Hematology of Infancy and Childhood, 3rd edn. WB Saunders, Philadelphia, 1987; pp 1028-1063.

4. Macdougall LG, Brown JA, Cohen MM, Judisch JM. C-monosomy myeloproliferative syndrome. A case of 7-monosomy. J Pediatr 1974; 84: 256-259.

5. Djernes BW, Soukup SW, Bove KE, Wong KY. Congenital leukemia associated with mosaic trisomy 9. J Pediatr 1976; 88: 596-597.

6. Shen JJ, Williams BJ, Zipursky A, Doyle J, Sherman SL, Jacobs OA, et al. Cytogenetic and molecular studies of Down syndrome individuals with leukemia. Am J Hum Genet 1995; 56: 915-925.

7. Weinstein HJ. Congenital leukemia and the neonatal myeloproliferative disorders asso-ciated with Down syndrome. Clin Hematol 1978; 7: 147-154.

8. Verma M, Rawat P, Das S, Kakkar N, Sohi I. Congenital acute myeloid leukemia in a case of Down syndrome. A case report. Indian J Hemat Blood Transf 2001; 19: 110-111.

9. Zipursky A, Peeters M, Poon A. Mega-karyoblastic leukemia and Down’s syndrome: a review. Pediatr Hematol Oncol 1987; 4: 211-230.

10. Suarez CR, Le Beau MM, Silberman S, Fresco R, Rowley JD. Acute megakaryoblstic leukemia in Down syndrome: report of a case and review of cytogenetic findings. Med Pediatr Oncol 1985; 13: 225-231.

11. Irving IM. Duodenal atresia and stenosis: annular pancreas. In: Lister J, Irving IM eds. Neonatal Surgery, 3rd edn. Butterworths, London. 1990, pp 424-441.

12. Bauer SB. Anomalies of the kidney and ureteropelvic junction. In: Campbell’s Urology, 7th edn. Editors. Walsh P.C. WB Saunders, Philadelphia, 1998; pp 1708- 1756.

13. Rickwood AMK. Urinary tract obstruction and dilatation in the newborn. In: Lister J, Irving IM eds. Neonatal Surgery, 3rd edn. Butterworths, London, 1990; pp 656- 677.

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