1. Case 287
Michael Gentry, MD Natalie Walker, Mark Pettenati, PhD, Michael Beaty, MD, David Grier, MD

2. Case Presentation
30-year-old female with a history of leukopenia & thrombocytopenia in the setting of pneumonia 8 months prior
BM biopsy at that time: Hypercellular marrow Erythroid/megakaryocytic hyperplasia No increase in blasts Karyotype: 45, XX, add(12)(p11.2),-17,20,+mar [10]/ 46,XX[10]
Persistant neutropenia/thrombocytopenia over the interval 8 months
ROS: daily loose stools

3. History of Present Illness
Recently admitted at an OSH for intractable lower back pain. Developed pneumonia with acute deterioration in status.
Transferred to our institution for suspected leukemia
Physical Findings: intubated height: 4 feet 10 inches weight: 70 pounds BMI:
Labs: WBC: 2.7 x 103/uL Hb: 9.2 g/dL Platelets: 27,000/uL

4. Imaging Lungs: Diffuse ground glass opacities
Pancreas: Fatty replacement of pancreas
Bone: diffuse lytic lesions
Radiological interpretation
Complete fatty replacement of the pancreas. Most commonly this is related to cystic fibrosis. However, given the absence of pulmonary bronchiectasis, as well as the history of leukemia, these findings could represent Shwachman-Diamond syndrome

5. Diagnostic Work-Up Bone Marrow Biopsy Flow Cytometry Cytogenetics
Genetic analysis for SD syndrome
Fatty replacement of pancreas
Short stature with evidence of malnourishment
Persistent cytopenias/MDS

6. Bone marrow

7. Bone marrow

8. Bone Marrow Aspirate

9. Peripheral Blood

10. Flow Cytometry Immunophenotype Positive Negative CD117 CD71 CD61
(wk)Glycophorin A
CD34
nTdT
CD13/15/33
CD10/20
CD3/5/138

11. Cytogenetics
65,X,i(X)(q10),+1,+2,+3,+6,+6,+8,+8,+10,add(12)(p13),+13,+14,+1 5,+19,+19,+20,+21,+21,+22,+22,+22,+mar[cp5]

12. Diagnosis Panel Consensus Diagnosis:
“Acute myeloid leukemia with myelodysplasia- related changes, blasts with erythroid/megakaryocytic differentiation, arising in a patient with Shwachman-Diamond syndrome”
Shwachman-Diamond syndrome
Homozygous SBDS mutation: c T>C
Heterozygous c A>G mutation

13. Shwachman-Diamond Syndrome
Rare inherited autosomal recessive disease
80-90% have mutations in SBDS gene, Ch 7q11(1,2)
Clinical features(3)
Pancreatic insufficiency
Hematological abnormalities
Most common: neutropenia
Other cytopenias
Increased risk of MDS/leukemia
Skeletal abnormalities

14. Leukemias arising in SDS
Increased risk for MDS & leukemia
Combined rate of developing MDS/AML (8-33%) (4)
AML most common leukemia(4)
Also rare reports of ALL, JMML(5)
Morphologic AML subtypes identified(5)
M0, M2, M4, M5, M6
Higher relative incidence of AML M6 (30%) than general AML population in one review(5)

15. SDS and MDS/AML
Donadieu J, et al. Classification of and risk factors for hematologic complications in a French national cohort of 102 patients with Shwachman-Diamond syndrome. Haematologica. 2012; Sep;97(9):
No correlation with specific SDS genotype and risk of hematologic complications
Risk of severe cytopenia correlated with early age of diagnosis and/or at least one low CBC value at time of diagnosis*
12 patients developed MDS/AML
Most frequent (6) cytogenetic abnormality: monosomy 7
2 patients with i(7)(q10)
9 patients with no abnormal blood counts
3 with i(7)(q10)
5 with del(20q)
*ANC<0.5 x 109/L
platelets < 100 x 109/L
Hb < 9 g/dL

16. Megakaryocyte-Erythroid Progenitor Cell

17. Markers defining lineages8,9,10,11,12
Erythroid
Megakaryocytic
Immunophenotype
(+)CD71
(+)glycophorin A
(+) hemoglobin A
(+)E-cadherin
(+)CD36
(+)CD105
(+)beta-spectrin
(+/-)CD117
(-/+) HLA-DR
(-/+) CD34
(-) CD33
(-) MPO
(-) TdT
(-) lymphoid markers
(+)CD41
(+)CD61
(+)CD42b
(+)vWF
(-/+) beta-spectrin
(-/+) CD117
(-/+) CD33
(-/+) CD13
(-)TdT
(-)lymphoid markers (except CD7)

18. AML- Megakaryocyte-Erythroid Progenitor
2008 WHO: Cases with erythroid-megakaryocyte features
Overlapping phenotypic features in cases of AML
Daniels L, et al. (2007) Acute myeloid leukaemia of mixed megakaryocytic and erythroid origin: a case report and review of the literature.
San Miguel et al. (1988) Leukemias with megakaryoblastic involvement: clinical, hematologic, and immunologic characteristics.
Ito et al. (1996) Expression of erythroid-specific genes in megakaryoblastic disorders.
Westfall et al. (2008) Concurrent megakaryocytic and erythroid chronic myelogenous leukemia blast crisis.
Human leukemia cell lines with overlapping megakaryocytic/erythroid phenotypes
JK-1, K562, HEL cell lines(15, 16)

19. AML M7 & Lytic Bone Lesions
Muler, J. H., et al. (2002) Acute megakaryocytic leukemia presenting as hypercalcemia with skeletal lytic lesions. European Journal of Haematology. 2002; 68: 392–396
Fisher D, Ruchlemer R, Hiller N, et al. Aggressive bone destruction in acute megakaryocytic leukemia: a rare presentation. Pediatr Radiol. 1997;27:20–22.
Kozlowski K, Halimun E. Generalized bone disease with abundant periosteal reaction in megakaryocytic leukemia. Eur J Pediatr. 1997;156:845–847.

20. Clinical Course and Treatment
Induction therapy with cytarabine and idarubicin
Nadir bone marrow: 10% cellular marrow with 10% blasts
Held additional chemotherapy due to her critical medical condition
Subsequently her status improved with recovery of her blood counts & she was discharged
Patient has since died

21. References
1Hashmi SK, et al. Comparative analysis of Shwachman-Diamond syndrome to other inherited bone marrow failure syndromes and genotype-phenotype correlation. Clin Genet May;79(5):
2Boocock GR, et al. Mutations in SBDS are associated with Shwachman-Diamond syndrome. Nat Genet Jan;33(1): Epub 2002 Dec 23.
3Rothbaum R, Perrault J, Vlachos A, Cipolli M, Alter BP, Burroughs S, Durie P, Elghetany MT, Grand R, Hubbard V, Rommens J, Rossi T. Shwachman-Diamond syndrome: report from an international conference. J Pediatr. 2002;141:266–70.
4Hoffman R, et al, eds. Hoffman: Hematology Basic Principles and Practice. 6th ed. Philadelphia: Elsevier Saunders, 2013.
5Arceci R, et al, eds. Pediatric hematology. 3rd ed. Malden: Blackwell Publishing Ltd, 2006.
6Donadieu J, et al. Classification of and risk factors for hematologic complications in a French national cohort of 102 patients with Shwachman-Diamond syndrome. Haematologica Sep;97(9):
7Appelbaum FR, et al, eds. Thomas’ Hematopoietic Cell Transplantation. 4th ed. Blackwell Publishing Ltd, Print.
8Mihova D, Zhang L. Acute Erythroid Leukemia: A Review. N A J Med Sci. 2012;5(2):
9Olsen RJ, Chang CC, Herrick JL, Zu Y, Ehsan A. Acute leukemia immunohistochemistry: a systematic diagnostic approach. Arch Pathol Lab Med Mar;132(3):
10Swerdlow S, et al, eds. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. IARC, 2008.
11Wolgast LR, et al. Spectrin isoforms: differential expression in normal hematopoiesis and alterations in neoplastic bone marrow disorders. Am J Clin Pathol Aug;136(2):300-8.
 12Fajtova M, et al. Immunophenotypic profile of nucleated erythroid progenitors during maturation in regenerating bone marrow. Leuk Lymphoma Apr 23.
13Daniels, L. , et al. Acute myeloid leukaemia of mixed megakaryocytic and erythroid origin: a case report and review of the literature. Acta Clin Belg (5):308–314.
14San Miguel JF, et al. Leukemias with  megakaryoblastic  involvement:  clinical,  hematologic, and immunologic characteristics. Blood. 1988 Aug;72(2):402-7.
15Ito E, Kasai, M, Toki T, Arai K, Yokoyma M. Expression of erythroid-specific genes in megakaryoblastic disorders. Leuk Lymphoma Nov;23(5-6):
16Westfall DE, Zhang L, Song S, Lee S. Concurrent megakaryocytic and erythroid chronic myelogenous leukemia blast crisis. Arch Pathol Lab Med Jun;132(6):
17Tani T, Ylänne J, Virtanen I. Expression of megakaryocytic and erythroid properties in human leukemic cells. Exp Hematol Feb;24(2):
18Alitalo R. Induced differentiation of K562 leukemia cells: a model for studies of gene expression in early megakaryoblasts. Leuk Res.  1990;14(6):
19Muler, J. H., et al. (2002), Acute megakaryocytic leukemia presenting as hypercalcemia with skeletal lytic lesions. European Journal of Haematology, 68: 392–396
20Fisher D, Ruchlemer R, Hiller N, et al. Aggressive bone destruction in acute megakaryocytic leukemia: a rare presentation. Pediatr Radiol 1997;27:20–22.
21Kozlowski K, Halimun E. Generalized bone disease with abundant periosteal reaction in megakaryocytic leukemia. Eur J Pediatr1997;156:845–847

22. Acknowledgements Michael Beaty, MD WFUBMC David Grier, MD WFUBMC Michael Oliphant, MD WFUBMC Changlee Pang, MD WFUBMC Mark Pettenati, PhD WFUBMC Natalie Walker, MT, BS WFUBMC

23. Questions