Myeloid proliferation in a newborn with down syndrome Agnihotri M, Kh...

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Agnihotri M
Khatib Y
Gujral S

LETTER TO EDITOR
Year : 2010 | Volume : 47 | Issue : 4 | Page : 470-471
Myeloid proliferation in a newborn with down syndrome

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Agnihotri M
Khatib Y
Gujral S
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M Agnihotri1, Y Khatib1, S Gujral2

1
R. N. Cooper Hospital, Vile Parle, Mumbai, India
2
Department of Pathology, Tata Memorial Hospital, Mumbai, India

Date of Web Publication

4-Dec-2010

Correspondence Address:
S Gujral
Department of Pathology, Tata Memorial Hospital, Mumbai
India
Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.73552

How to cite this article:

Agnihotri M, Khatib Y, Gujral S. Myeloid proliferation in a newborn with down syndrome. Indian J Cancer
2010;47:470-1
How to cite this URL:
Agnihotri M, Khatib Y, Gujral S. Myeloid proliferation in a newborn with down syndrome. Indian J Cancer
[serial online] 2010 [cited 2015 Jul 29];47:470-1. Available from: http://www.indianjcancer.com/text.asp?
2010/47/4/470/73552

Sir,
Approximately 10% of the newborns with Down syndrome (DS) present with leukocytosis and circulating
Breast Cancer Patients
myeloblasts. [1],[2] The 2008 WHO Classification of Tumor of Hematopoietic and Lymphoid Tissue describes
Advanced Cancer Treatment
myeloid proliferations in DS as a separate entity. It has been subtyped as transient abnormal myelopoiesis (TAM)
and acute megakaryoblastic leukemia (AMKL) associated with DS. [3] TAM is commonly present in the first
Ovarian Cancer
week of life as thrombocytopenia, leukocytosis, and hepatosplenomegaly with megakaryocytic blasts. In a
majority of the cases it resolves spontaneously by 3 months of age. [1],[2],[3] However, 20-30% of these children
develop AMKL subsequently in 1-3 years. [1],[2],[3] Thus, any DS neonate with elevated white cell counts and
circulating blasts is labeled as TAM and followed. TAM develops almost exclusively in newborns with DS or
trisomy 21 mosaics. [1],[4]
A male neonate was born full-term normal delivered at home (weight 1.85 kg), developed respiratory distress and
rash on day 1 and was admitted at neonatal intensive care unit. The mother was 35 years old, multigravida with 2
other normal children. This infant had a dysmorphic facies, flat face, upward slanted palpebral fissure, simian
crease with short broad hands, hypotonia, bilateral undescended testes and absence of middle phalanx of the little
finger. Peripheral cyanosis, icterus, and hepatosplenomegaly were present. Complete blood count revealed
hemoglobin of 19.3 gm%, total leukocyte count of 1,02,300 cells/mm [3] , and a platelet count of 80,000/mm [3] .

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Myeloid proliferation in a newborn with down syndrome Agnihotri M, Kh... Page 2 of 2

Manual differential count showed 54% blasts, 02% promyelocytes, 04% myelocytes, 02% metamyelocytes, 24%
polymorphs, and 14% lymphocytes. There were 50 nucleated red cells per 100 white cells. Bone marrow (BM)
examination showed 70% blasts with basophilic cytoplasm and cytoplasmic blebs. Nuclei showed finely
dispersed chromatin with 2-3 nucleoli. Blasts expressed CD34, CD41, CD61, CD117, CD33, and CD4. Serum
indirect bilirubin was high (10.2 mg%). Repeat total white blood cell counts done on day 4 and day 6 were 75,700
and 49,600 cells per cubic mm, respectively. He had oral and rectal bleeding on day 6. Whole blood and fresh
frozen plasma were given; however, he had cardiorespiratory arrest and expired. Autopsy could not be performed.
Click on image for details.

No tissue was available for cytogenetic confirmation of Trisomy 21, but the baby had classical phenotypic
features of DS. The usual age of presentation is from the 1st week of life with a range between 1 and 65 days. [2],
[5]
Our patient presented on day 1 of life. Clinical features of hepatosplenomegaly, skin rash, respiratory distress,
thrombocytopenia, and leukocytosis were noted as reported by others. [2],[5] However, a few may be asymptomatic
with circulating blasts in the blood. [2],[5] Blasts percentage was more in BM as compared with the peripheral
blood, unlike as described in the literature. [1],[2],[3] Blast morphology, myeloperoxidase negativity, and expression
of CD41 and CD61 with other myeloid markers confirming its megakaryocytic lineage. [1],[5]
Dysmegakaryopoiesis [1] was not seen. Diagnosis of myeloid proliferation in DS was rendered favoring TAM
because of DS phenotype, age (one day old), leukocytosis, thrombocytopenia, and circulating blasts of
megakaryocytic type. WHO mentions 2 subtypes of myeloid proliferation in DS; however, definite differentiating
criteria are not clear. It is necessary to diagnose TAM and differentiate it from AMKL as it requires no treatment
except follow-up.

References
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5.

Apollonsky N, Shende A, Ouansafi I, Brody J, Atlas M, Aygun B. Transient myeloproliferative disorder in

neonates with and without Down syndrome: A tale of 2 syndromes. J Pediatr Hematol Oncol
2008;30:860-4.
[PUBMED] [FULLTEXT]
Choi JK. Hematopoietic disorders in down syndrome. Int J Clin Exp Pathol 2008;1:387-95.
[PUBMED] [FULLTEXT]
Bauman I, Nieneyr CM, Brunning RD. Myeliod proliferation related to Down syndrome. WHO
Classification of Tumour of Hematopoietic and Lymphoid tissue. Lyon: IARC; 2008. p. 142-4.
Massey GV. Transient leukemia in newborns with Down syndrome. Pediatr Blood Cancer 2005;44:2932.
[PUBMED] [FULLTEXT]
Massey GV, Zipursky A, Chang MN, Doyle JJ, Nasim S, Taub JW, et al. A prospective study of the natural
history of transient leukemia (TL) in neonates with Down syndrome (DS): Children's Oncology Group
(COG) study POG-9481. Blood 2006;107:4606-13.
[PUBMED] [FULLTEXT]

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