Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 48, Num. 2, 2011, pp. 264-265

Indian Journal of Cancer, Vol. 48, No. 2, April-June, 2011, pp. 264-265

Letter to Editor

Leukemia with malaria: An unusual presentation

N Thapliyal¹, V Rawat², S Singh¹, RS Jha¹

¹ Department of Pathology, Government Medical College, Haldwani, Nainital, India
² Department of Microbiology, Government Medical College, Haldwani, Nainital, India

Correspondence Address: N Thapliyal Department of Pathology, Government Medical College, Haldwani, Nainital India naveendun@yahoo.com

Code Number: cn11066

DOI: 10.4103/0019-509X.82889

Sir,

Chronic myeloid leukemia (CML) is malignant proliferation of myeloid elements at all stages of differentiation, and has two distinct phases − chronic phase and blast crisis/accelerated phase.

Malaria, a protozoan disease transmitted by Anopheles mosquitoes, is also a serious and life-threatening disease. ^[1] Although, the tarai (foothill) region of Uttarakhand is endemic area for the malaria, but malaria complicating malignant neoplastic disease is very unusual. ^[1] Recently, we observed a case of leukemia complicated by malaria at our hospital.

A 35-year old female presented with generalized weakness for the past 1 year and fever with chills and rigors for last 1 month to the out patient department of medicine. On examination, she was anemic with moderate degree of hepatosplenomegaly. Clinically, malaria was suspected. Blood sample was sent to the Pathology Department for the routine investigation. Aside from the picture of leukemia, peripheral blood smear revealed the presence of trophozoite forms of Plasmodium vivax. [Figure - 1] and [Figure - 2] Her Hb% was 9.6 gm%, red cell mass was reduced, total leukocyte count was about 3.0 lacs/cmm, differential leukocyte count showed: neutrophils − 47%, lymphocytes − 02%, eosinophils − 02%, basophils − 05%, monocytes − 02%, myelocytes − 24%, metamyelocytes − 12%, and blasts − 06%. Her platelet count was 1.55 lacs/cubic millimeter. The diagnosis of CML with malaria for P. vivax was made. To doubly confirm the concurrent malaria, card test for malaria was performed as per manufacturer′s instructions, and it was found reactive for P. vivax (Biomed card) [Figure - 3].

Malaria, a major health problem in India and caused by four species of Plasmodia (vivax, falciparum, malariae, and ovale) and anopheline mosquito as a vector. ^[2]

The present case revealed the CML is complicated by P. vivax. Tapper et al, reported such two cases of acute myeloid leukemia (AML) infected with P. vivax, which were caused by blood transfusion. ^[4] Our case does not have the history of blood transfusion and being a resident of endemic area, malaria was most probably by the vector borne.

Nirmala et Al., also reported a series of cases of drug-resistant P. falciparum malaria complicating hematologic malignancies including leukemias and lymphomas. They communicated 31 cases of hematological malignancies microscopically revealed P. falciparum. ^[4] All these cases were from the endemic areas of eastern Uttar Pradesh.

Another study by Rapoport et al., reported three cases of malaria complicating the Hodgkin`s lymphoma, Non-Hodgkin`s lymphoma, and acute lymphoblastic leukemia, all the three cases showed neutropenia. ^[5] The present case is the case of chronic myelogenous leukemia showing marked proliferation of myeloid series with all ranges of maturation and the mature neutrophils are toward the lower range of normal limit. It has been recorded in literature that neutrophils in CML are functionally defective and so these patients are vulnerable to get infections. ^[6]

In hematologic malignancies, there is impaired phagocytosis by neutrophils, defective production of antibodies, as well as impaired cellular immunity alone or in combination. Decreased cell-mediated immunity causes impaired Th1CD4+ lymphocytes and macrophage function resulting into increased risk of infections with intracellular bacteria, fungi, parasites, and viruses. ^[6]

It is suggested that malaria should be considered as a possible cause or a complicating factor of fever with hepatosplenomegaly in patients of malignancy especially in endemic malaria areas.

Patients presented with generalized weakness with hepatosplenomegaly developing fever with chills and rigors must be evaluated utmost care for the malignancy as well as for malaria.

References

Copyright 2011 - Indian Journal of Cancer

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