Blood & Lymphoreticular System

Auer Rods

Auer rods are needle- or rod-shaped crystalline structures derived from myeloid cell granules. They are most commonly seen in acute myeloid leukemia (AML), but are also associated with other, high-grade myelodysplastic syndromes and neoplasms.

Auer rods indicate the lineage and neoplastic nature of the ongoing disease. Bundles of unusually long Auer rods are very characteristic (but not totally specific) for AML with t(8;21)(q22;q22) translocation.

CNS Involvement in ALL

CNS involvement in ALL usually takes the form of relapse and occurs in 5-10% of cases. CNS positivity at the time of diagnosis is associated with a worsened prognosis.

CNS involvement presents with nonspecific neurologic complaints such as headache, dizziness, visual field deficits, or as leukemic meningitis. Rarely, parenchymal hemorrhage due to vascular infiltration of leukemic cells can be the presenting picture.

The central nervous system is a sanctuary for ALL, and CNS prophylaxis is an essential part of therapy.

Cranial radiation therapy (CRT) was once standard for all ALL patients but has been largely replaced by intrathecal or systemic chemotherapy in lower-risk patients due to the risk of secondary brain tumors, endocrinopathies and neurocognitive deficits.

Bone Marrow Biopsy

Bone marrow biopsy is used to establish the diagnosis of ALL and identify its subtype.

The normal bone marrow is comprised of less than 5% of blasts, while leukemic marrow is hypercellular and almost completely infiltrated with leukemic blasts.

ALL should be suspected if the marrow contains more than 5% blasts, but the diagnosis should not be made on a single smear showing less than 25% blasts.

Daunorubicin, Vincristine, and Prednisolone

Over recent years, the intensity of induction therapy has increased.

The original combination of vincristine and a steroid has evolved into a regimen consisting of vincristine, a steroid and an anthracycline such as daunorubicin, or quadruple therapy, which adds an asparaginase product such as pegylated asparaginase.

Complete remission is possible in 85-95% of cases, while the remainder will suffer from persistent disease or death.

Band Keratopathy

Band keratopathy is a chronic degenerative disease that can be associated with many disorders, especially inflammatory conditions such as Stills disease (juvenile rheumatoid arthritis). It is characterized by deposition of gray to white opacities in the superficial layers of the cornea, and develops over months to years.

While the underlying pathophysiology remains unknown at the time of this writing, it appears to represent a calcifying tendency of the comorbid condition.

Malignant Hypercalcemia

Hypercalcemia of malignancy is rare in children, but has been reported in rhabdomyosarcoma, hepatoblastoma, Hodgkin's and non-Hodgkin's lymphoma, brain tumors, neuroblastoma, angiosarcoma, ALL and AML.

It is an extremely rare primary presentation of ALL, and thus may prolong the diagnosis. It usually entails a non-specific constellation of nausea, vomiting, abdominal pain, anorexia, constipation and weight loss.

Treatment is with the aggressive administration of IV fluid and in more severe cases, IV pamidronate, furosemide, and dexamethasone. Emergency dialysis may be required in refractory cases.

Metastatic activity of ALL

Metastasis is common in the natural course of many malignancies. It results from the ability of tumor to spread from the site of origin to local or distant anatomical sites.

Since leukocytes are able to access nearly all parts of the body for immune protection, it can be inferred that leukemia has an inherent ability to metastasize.

Metastatic activity affecting the bones and or direct trauma to the bones from blast proliferation, as seen in this case, can damage them and induce osteoclastic activity. This increases resorption of calcium into the blood, leading to hypercalcemia.


BAIN BJ. Auer rods or McCrae rods? Am J Hematol [online] 2011 Aug, 86(8):689 [viewed 12 January 2016] Available from: doi:10.1002/ajh.21978

2. ABRAMSON N, MELTON B. Leukocytosis: basics of clinical assessment. Am Fam Physician [online] 2000 Nov 1, 62(9):2053-60 [viewed 12 January 2016] Available from:

3. CONTER V, RIZZARI C, SALA A, CHIESA R, CITTERIO M, BIONDI A. Acute Lymphoblastic Leukemia Orphanet Encyclopedia. December 2004. [viewed 12 January 2016] Available from:

4. NASCIMENTO H, YASUTA MK, MARQUEZAN MC, SALOMãO GH, GONZáLEZ D, FRANCESCONI C, MUCCIOLI C, BELFORT R JR. Uveitic band keratopathy: child and adult J Ophthalmic Inflamm Infect [online] 1/01/01 00:00:35 [viewed 13 January 2016] Available from: doi:10.1186/s12348-015-0062-z

5. O'CONNOR GR. Calcific band keratopathy. Trans Am Ophthalmol Soc [online] 1972/01/01 00:00:58-81 [viewed 13 January 2016] Available from:

6. ŽOFKOVá I. Hypercalcemia. Pathophysiological aspects. Physiol Res [online] 2015 Nov 24 [viewed 14 January 2016] Available from:

7. BAHOUSH G, MIRI-ALIABAD G. Severe Hypercalcemia: A Rare and Unusual Presentation of Childhood Acute Lymphoblastic Leukemia Int J Hematol Oncol Stem Cell Res [online] 2014/01/01 00:00, 8(2):38-40 [viewed 14 January 2016] Available from:

8. PERCIVAL RC, YATES AJ, GRAY RE, NEAL FE, FORREST AR, KANIS JA. Role of glucocorticoids in management of malignant hypercalcaemia. Br Med J (Clin Res Ed) [online] 1984/08/04 00:00, 289(6440):287 [viewed 14 January 2016] Available from:

9. STEWART ANDREW F.. Hypercalcemia Associated with Cancer. N Engl J Med [online] 2005 January, 352(4):373-379 [viewed 14 January 2016] Available from: doi:10.1056/NEJMcp042806

10. 1. SISON E. A. R., SILVERMAN L. B.. CNS prophylaxis in pediatric acute lymphoblastic leukemia. Hematology [online] December, 2014(1):198-201 [viewed 21 January 2016] Available from: doi:10.1182/asheducation-2014.1.198

11. HAMDI A, MAWAD R, BASSETT R, DI STASI A, FERRO R, AFROUGH A, RAM R, DABAJA B, RONDON G, CHAMPLIN R, SANDMAIER BM, DONEY K, BAR M, KEBRIAEI P. Central Nervous System Relapse in Adults with Acute Lymphoblastic Leukemia after Allogeneic Hematopoietic Stem Cell Transplantation Biol Blood Marrow Transplant [online] 2014/11/01 00:00, 20(11):1767-1771 [viewed 21 January 2016] Available from: doi:10.1016/j.bbmt.2014.07.005

12. SUNG SH, JANG IS. Isolated Central Nervous System Relapse of Acute Lymphoblastic Leukemia Brain Tumor Res Treat [online] 2014/10/01 00:00, 2(2):114-118 [viewed 22 January 2016] Available from: doi:10.14791/btrt.2014.2.2.114

13. PUI CHING-HON, EVANS WILLIAM E.. Treatment of Acute Lymphoblastic Leukemia. N Engl J Med [online] 2006 January, 354(2):166-178 [viewed 14 January 2016] Available from: doi:10.1056/NEJMra052603

14. COOPER SL, BROWN PA. Treatment of Pediatric Acute Lymphoblastic Leukemia Pediatr Clin North Am [online] 2015/02/01 00:00, 62(1):61-73 [viewed 14 January 2016] Available from: doi:10.1016/j.pcl.2014.09.006

15. ALEXANDER S.. Clinically defining and managing high-risk pediatric patients with acute lymphoblastic leukemia. Hematology [online] December, 2014(1):181-189 [viewed 17 January 2016] Available from: doi:10.1182/asheducation-2014.1.181

  1. 16. TRENDOWSKI MATTHEW. The inherent metastasis of leukaemia and its exploitation by sonodynamic therapy. Critical Reviews in Oncology/Hematology [online] 2015 May, 94(2):149-163 [viewed 23 January 2016] Available from: doi:10.1016/j.critrevonc.2014.12.013