Patient Presentation

A 58-year-old man presented to a local hospital in March 2022 with nausea and vomiting. Blood tests revealed:

• Elevated white blood cell count (WBC): 25.3 × 10⁹/L

• Low hemoglobin (HB): 65 g/L

• High platelet count (PLT): 190 × 10⁹/L

Considering these findings, doctors suspected acute leukemia. Bone marrow examination showed active mononuclear system hyperplasia with abnormal cells (51% immature mononuclear cells). Further tests identified mutations in genes associated with AML: DNMT3A, FLT3-TKD, and IDH2. A chest CT scan identified two pulmonary tuberculosis lesions.

Laboratory Findings

• Blood counts:

  • WBC: Initially elevated (25.3 × 10⁹/L), reached a peak of 99 × 10⁹/L during treatment, then decreased to 4.1 × 10⁹/L after therapy.

  • Neutrophils: Followed a similar trend as WBC.

  • HB: Initially low (65 g/L), improved slightly to 64 g/L after anti-leukemia therapy, then significantly increased to 121 g/L after bone marrow transplant.

  • PLT: Initially high (190 × 10⁹/L), fluctuated during treatment, but ultimately increased to 242 × 10⁹/L after transplant.

• Bone marrow examination:

  • Initial examination showed active mononuclear system hyperplasia with 51% abnormal cells.

  • After one course of VA regimen therapy, bone marrow tests showed improvement with only 4% primitive mononuclear cells.

  • Flow cytometry of bone marrow showed no blasts with abnormal immunophenotypes after HVA regimen therapy cycles.

  • Subsequent bone marrow tests remained normal.

• Chest CT scan:

  • Revealed two pulmonary tuberculosis lesions initially.

  • Follow-up scans showed progressive reduction in lung TB foci after anti-TB therapy.

• Sputum smear:

  • Initially positive for acid-fast bacillus (AFB) 3+.

  • Became negative after anti-TB treatment.

• Next-generation sequencing (NGS):

  • Detected mutations in DNMT3A (48.02%), FLT3-TKD (36.3%), and IDH2 (45.95%) genes initially.

  • Subsequent tests showed varying mutation rates for these genes, but no mutations were detected in IDH2 and FLT3-TKD after HVA therapy.

Treatment

• The patient received supportive care for his symptoms.

• Due to high WBC count, he was given hydroxycarbamide to reduce it.

• Anti-TB therapy with HRZE regimen (isoniazid, rifampicin, pyrazinamide, ethambutol) was initiated.

• After TB was under control, the patient received anti-leukemia therapy with VA regimen (venetoclax, azacytidine). Due to drug interaction, the anti-TB regimen was adjusted.

• The patient then underwent three cycles of HVA regimen anti-leukemia therapy (homoharringtonine, venetoclax, azacytidine).

• Intrathecal chemotherapy with cytarabine, methotrexate, and dexamethasone was administered to prevent central nervous system leukemia.

• Ultimately, the patient underwent a bone marrow transplant.

Outcome

Following treatment, the patient's bone marrow tests became normal, lung TB lesions showed significant reduction, and blood counts improved considerably. He then underwent a bone marrow transplant.