76 years old man with RAEB-1 transformed in RAEB-2 in 2013. 46XY (BM examination). Two different type of inclusion: the first one like crystal block (on the right) the second one like "target" with purple center and light border (on the left). As in this photo, the inclusion are present in blast cells as well as in mature dysplastic granulocytes. Crystal block was previously observed also by Dr. A. Merino in a case of AML M4 (BJH. Images of Haematology, 2005; 131 - 286)
What percentage of cells contain the inclusions? Have you considered that these may be virus inclusion bodies? If you have fresh sample you may want to have them fixed and embedded for EM analysis and/or send to a virology lab an have the co-culture the patient cells with virus sensitive cell and see if they detect any cytopathic effects.
The Daniel hypothesis is suggestive but we observed that the inclusions are present in conjunction with the leukemic stage and disappear during remission. The percentage of cells with inclusion is about 3-4%. We have already scheduled electron microscopy analysis in a (possible) subsequent blast crisis. Some characteristics of inclusions (azurophilia, Sudan Black, appearance like rods) are according to Mark hypothesis of Auer bodies and It was also my first hypothesis. However,….
1. After the first description in 1906 by J. Auer, the Auer bodies was observed in millions of leukaemia, never with the morphology of this case;
2. In my sample, there are two different inclusion: the first one brick-shaped; the second one target-shaped.
3. In the WHO AML with t(8;21)(q22;q22) few blast can “show very large granules (pseudo Chediak-Higashi)……..Auer rod are frequently found and appears a single long and sharp rod with tapered ends; they may be detected in mature neuthrophils”. My patient is 46XY.
I'm agree withMark L Mitchell, and Mohammad Ali Yavari, it's mostly variants of Auer Rods.
I agree with the origins of these inclusion arising from abnormal granule formation
stains with Sudan black B or myeloperoxidase or chloroacetate set eraseset erase
These could be Charcot-Leyden crystals. Seen them once in an AML and it is definitely described in the literature.
Thanks, David. May be. I found some papers regarding AML with Charcot-Leyden crystals ( Acute myeloid leukemia with Charcot-Leyden crystals.Manny JS, Ellis LR.
Blood. 2012 Jul 19;120(3):503; Acute myeloid leukaemia with mutated NPM1 presenting with extensive bone marrow necrosis and Charcot-Leyden crystals.
Taylor G, Ivey A, Milner B, Grimwade D, Culligan D. Int J Hematol. 2013 Sep;98(3):267-8; Charcot-Leyden crystals associated with acute myeloid leukemia: case report and literature review. Khrizman P, Altman JK, Mohtashamian A, Peterson L, Chen YH, Tallman MS. Leuk Res. 2010 Dec; 34(12):e336-8.). However the Charcot Leyden morphology is like in attached slide: bipyramidal crystals shaped as hexagons, different from my case... I'm stumped.
I'll try to summarize: three different hypotesis.
These days I found numerous articles (particularly of the seventies and eighties) that describe the crystal structure of the Auer bodies. In one of these articles (Pearson EC.structure of Auer rods in acute myeloblastic leukaemia (AMyL).J Clin Pathol. 1986 May;39(5):569-72.) we can observe a very explanatory image. Consequentially, now i agree with all Collegues who had supposed that the block inclusions are Auer bodies.
I would like to thank all that participated in the discussion. All I have been of help and I have spurred a more careful search of bibliographic references.
Hi Antonio
i would suggest sending your case to the New England Journal of Medicine as a photo entry submission
you would need the special stains to be done to confirm positive staining
As suggested by Dr Goldberg, it would be very interesting to do some cytochemistry with Sudan Black, combined esterase (chloroacetate/alpha naphthyl esterase) and PAS to find out the nature of the inclusion. It would be extremely unlikely to be virus (too large). It doesn't really look like Auer rod. C-L crystal is a possibility. If you still have some fresh material, you could do some fancy tests (EM, polarised light microscopy/birefringence to demonstrate organic crystals.
As suggested by jack Goldberg, I published additional images and a short comment on British Journal of Haematology 176(2):156 · January 2017 DOI: 10.1111/bjh.14405
Thanks everyone for the interesting discussion
- Badges
- Science topic
- Similar topics
- Medicine
- Pathology
- Clinical Pathology