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Eosinophilia can occur due to a plethora of allergic, infective, neoplastic and idiopathic conditions. Hypereosinophilic syndrome (HES) is characterised by sustained eosinophilia and multiorgan dysfunction in the absence of an identifiable cause. It may range from a self-limiting condition to a rapidly progressive life-threatening disorder, of which ischaemic stroke is a rare presentation. Such episodes can rarely be the presenting manifestation, and may develop before any other laboratory abnormality or organ involvement. We report a case of HES presented with multiorgan (neurological and renal) involvement, managed successfully with steroids and cytoreductive therapy. High initial absolute eosinophil count can be a clue to the diagnosis and early treatment should be initiated in such patients, to prevent fatal outcomes.

Objective B-lymphocyte progenitors, namely the hematogones (HGs), may pose problems in morphological assessment of bone marrow, not only during the diagnostic workup but also while evaluating bone marrow for remission status following chemotherapy. Here, we describe a series of 12 cases of acute lymphoblastic leukemia (ALL) that included both B-ALL and T-ALL cases, which were evaluated for remission status and revealed blast-like mononuclear cells in bone marrow in the range of 6 to 26%, which on immunophenotypic analysis turned out to be HGs. Materials and Methods This is a case series of 12 ALL cases who were undergoing treatment at the Army Hospital (Referral and Research), New Delhi. All these cases were under workup for post-induction status (day 28) and to check for suspected ALL relapse. Bone marrow aspirate (BMA), biopsy, and immunophenotyping were performed. Multicolored flow cytometry was performed using CD10, CD20, CD22, CD34, CD19, and CD38 antibodies panel. Results BMA assessment of 12 cases revealed a maximum of 26% blastoid cells and a minimum of up to 6%, raising the suspicion of hematological relapse. However, on clinical assessment, these patients were well preserved, with preserved peripheral counts. Hence, marrow aspirates were subjected to flow cytometry using the CD markers panel, as discussed above, which revealed HGs. These cases were followed by minimal residual disease (MRD) analysis that revealed MRD-negative status, further confirming our findings. Conclusion This case series highlights the importance of morphology and bone marrow immunophenotyping in unveiling the diagnostic dilemma in post-induction ALL patients.

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