No abstract

Acute myeloid leukemia (AML) is the fifth most common malignancy in children. Extramedullary involvement in acute myeloid leukemia is rare and can be seen in soft tissues, central nervous system, skin and lymphoreticular organs. The clinical presentations can often be non‐specific and hence, the diagnosis can be very challenging, especially in cases without a prior hematologic diagnosis. We report a case of pediatric acute monocytic leukemia presenting with generalized lymphadenopathy and cutaneous rash. Fine‐needle aspiration was performed from the lymph nodes and a cytologic diagnosis of infiltration by a lymphoreticular malignancy was suggested. Peripheral blood, bone marrow and cerebrospinal fluid involvement were noted subsequently. Flow cytometry on the bone marrow aspirate confirmed a diagnosis of acute monocytic leukemia. The index case besides highlighting an uncommon presentation of acute monocytic leukemia in a toddler, also emphasizes the need to consider acute monocytic leukemia as a cytomorphologic differential in such presentations.

Circumscribed hypokeratosis of palms and soles is a rare dermatosis, usually affecting women. Diagnosis is mainly based on the clinical characteristics, including the clinical appearance and anatomical site of the skin lesions and on the demographic features of the affected patients, usually middle-aged to elderly women. Skin biopsy may be performed to confirm clinical diagnosis. Optical coherence tomography (OCT) is a technique that has been undergone substantial development in dermatology in recent years, and its use in clinical practice has been growing progressively. Several dermatological conditions have been studied with this tool, but to our knowledge, it has not been used to investigate this form of hypokeratosis. We report a case of circumscribed palmar hypokeratosis for which diagnosis was confirmed by OCT, which was performed as the patient was reluctant to undergo skin biopsy because of its invasiveness. We highlight the potential use of OCT in obtaining a virtual skin biopsy to confirm clinical diagnosis and identify preclinical skin lesions amenable to early treatment.

To the Editor: ZNF384 (zinc finger protein 384) rearrangements are recently recognized cytogenetic abnormalities. Forty-eight percent of mixedphenotype acute leukaemia (MPAL), B/myeloid 1 and 4% of B-cell precursor acute lymphoblastic leukaemia (BCP-ALL) 2 show this rearrangement. Several fusion partners of ZNF384 have been described, the most common being TCF3 and EP300, but also include ESWR1, TAF15, CREBBP, ARID1B, SYNRG and BMP2K. 1-3 We report a challenging case with TCF3-ZNF384 rearrangement that initially presented as BCP-ALL but showed the emergence of a large myeloid blast subset following 1 week of high-dose steroid therapy. A 2-year-old female presented with fever and pallor of 1 week duration. Examination revealed mild hepatomegaly and splenomegaly. The haemoglobin was 46 g/L, platelet count 14.0 × 10 9 /L and total leukocyte count 14.7 × 10 9 /L. Peripheral blood film showed 62% blasts (Figure 1A,B). Bone marrow aspiration revealed 82% blasts without Auer rods but with cytochemical myeloperoxidase (MPO) positivity in 2% of the blasts. On flow cytometry, the blasts expressed bright CD19, cytoplasmic CD79a, cytoplasmic CD22 and CD33, along with dim expression of CD10 and CD13 (Figure S1). However, cytoplasmic myeloperoxidase (anti-MPO) expression was absent. Fluorescent in situ hybridisation (FISH) testing with dual-colour dual-fusion probes for BCR-ABL1 and ETV6-RUNX1, and dual-colour break-apart probes for KMT2A and TCF3 (CytoTest Inc. Rockville, MD, USA) revealed presence of TCF3 translocation in 80% of cells (Figure 1E). TCF3-PBX1 and TCF3-HLF translocations were excluded using a tri-colour probe (Cytocell Ltd, Cambridge). In view of absence of metaphase, further FISH testing was performed using a commercially available dual-colour break-apart probe (ZytoVision GmbH, Germany) that confirmed rearrangement of ZNF384 (Figure 1G). A diagnosis of BCP-ALL with TCF3-ZNF384 [t(12;19)(p13;p13)] rearrangement was rendered, following which the child was initiated on the standard-risk BCP-ALL protocol of the Indian Childhood Collaborative Leukaemia Group (ICiCLe), comprising a prephase of prednisolone 60 mg/m 2 /day in three divided doses. 4

Hence, rigorous monitoring of platelet count and coagulation profile is required in patients taking this drug with other chemotherapeutic drugs and those having normal platelet counts. To best of our knowledge, this is the first report of thrombocytopenia induced by resveratrol and we hope to bring attention to this inadvertent side effect of a commonly used antioxidant. CONFLICT OF INTERESTNone. ORCID Garima Dabas