CASE�REPORT ABSTRACT Association of acute myeloid leukaemia with bone marrow plasmacytosis is a rare phenomenon with diverse underlying pathogenetic mechanisms. We report a case of a 75 years old diabetic male diagnosed as suffering with plasmacytosis. There were no lytic bone lesions or Bence‐Jones proteinuria. Serum protein electrophoresis did not show a monoclonal band. A presumptive diagnosis of AML with reactive plasmacytosis was made. Possible conditions which can be considered in differential diagnosis are discussed. Key Words: Acute Myeloid Leukaemia, Multiple Myeloma, Reactive Plasmacytosis. showed 75%blast cells and an increase in the plasma cells to 15% (Fig 1). BM trephine showed prominent plasma cells present interstitially as well as in small clumps (Fig 2). Diagnosis of AML with plasmacytosis was considered and further investigations were done to rule out concomitant MM. Skeletal survey did not show any lytic lesions. Urine examination for Bence‐Jones proteins was negative. S e r u m p r o t e i n e l e c t r o p h o r e s i s r e v e a l e d hypoalbuminaemia and a polyclonal increase in gamma globulins. No paraprotein band was detected. Serum free light chain assay was not done due to non availability. Analytical immunocytometry revealed 'AML with differentiation' (FAB type: AML‐ M2). Cytogenetics showed a normal karyotype. A presumptive diagnosis of AML‐M2 with reactive plasmacytosis was made and patient was shifted to the oncology ward but he died the next day before chemotherapy could be initiated. (Total duration of stay at the hospital was 12 days). Discussion Reactive BM plasmacytosis is characterized by an increase in the percentage of plasma cells above the normal, i.e. more than 3% but generally it does not 5 exceed 20%. It is seen in chronic infections, autoimmune diseases, connective tissue disorders, diabetes mellitus and malignancies. Rare causes include angioimmunoblastic lymphadenopathy and multicentric Castleman's disease. In AML , reactive BM plasmacytosis may be due to the presence of e i t h e r s o m e c o n c o m i t a n t , o r p r e c e d i n g inflammatory or infectious disorder and the plasma cells are considered to proliferate due to persistent 3 antigenic stimulation. Paracrine stimulation by interleukin (IL)‐6 secreted by leukaemias cells has 2,6,7 also been proposed as a cause. Our patient was a known diabetic and patients with diabetes mellitus Introduction Association of acute myeloid leukaemia (AML) with bone marrow (BM) plasmacytosis is a rare phenomenon with only a few cases reported in the 1 l i t e r a t u r e . T h e u n d e r l y i n g p a t h o g e n e t i c mechanisms causing BM plasmacytosis in patients of AML appear to be diverse as shown in the table. In the literature it has been mainly reported to occur in patients of AML as reactive proliferation discovered at the time of diagnosis; after induction‐ chemotherapy and rarely with simultaneous 2‐4 occurrence of multiple myeloma (MM). We report a case of AML with reactive plasmacytosis in an elderly diabetic and discuss the differential diagnosis. Case Report A 75‐year‐old male patient presented with complaints of low grade fever and lassitude of two month duration in the Medical OPD of Military Hospital Rawalpindi. He was a known case of type 2 diabetes mellitus for the past 25 years. On examination, he was pale and emaciated. Blood counts revealed pancytopenia with hemoglobin of 9 6.7 g/dl, white blood cell count of 1.8x10 /l and 9 platelet count of 87x10 /l. Peripheral film showed rouleaux formation and ESR was 130 mm at the end of first hour. Serum urea and creatinine levels were raised (15.8 mmol/l and 225 μmol/l respectively). Serum calcium levels were normal. His BM aspirate Acute Myeloid Leukaemia with Plasmacytosis 1 2 3 Yasmin Akhtar , Saqib Qayyum Ahmad , Shahid Jamal JIIMC 2016 Vol. 11, No.4 Correspondence: Dr. Yasmin Akhtar Department of Haematology Army Medical College, Rawalpindi E‐mail: aftersunset79@yahoo.com 1 2,3 Department of Haematology / Pathology Army Medical College, Rawalpindi Funding Source: NIL; Conflict of Interest: NIL Received: Aug 30, 2016; Revised: Oct 10, 2016 Accepted: Nov 20, 2016 AML with Plasmacytosis 189 are prone to acute and chronic infections, which might have been responsible for reactive plasmacytosis. AML with reactive plasmacytosis has to be differentiated from a very rare, simultaneously 4,7 occurring AML with concomitant MM. This is important because the latter requires different therapeutic approach. Clues from history, clinical examination, and presumptive. Cytological features may help to differentiate reactive plasmacytosis from MM but no discriminatory cut‐off value of plasma cells percentage in the BM has been defined. Normally, plasma cells are scattered interstitially and may be seen associated with macrophages and around the 5 capillaries. In reactive plasmacytosis, the plasma cells have mature nuclear and cytoplasmic characteristics, although binucleate forms may also be seen. A few small clumps may also be seen in case of reactive plasmacytosis but the number of plasma 5 cells in the clumps is generally less than ten. The presence of plasma cell dysplasia and plasmablasts is strongly suggestive of multiple myeloma. Cytological features in our patient favoured reactive plasmacytosis. Patients with mu ltip le myelo ma ( MM) o r monoclonal gammopathy of undetermined significance have an increased inherent risk of developing acute myeloid leukemia (AML) which is 4 independent of prior chemotherapy. A common aetiologic agent could be responsible for some cases o f co n co m i ta nt A M L a n d M M . A M L i s a morphologically, genetically, phenotypically and b i o l o g i c a l l y h e t e r o g e n e o u s d i s o r d e r a n d 2 plasmacytosis is seen in 6‐7 % of cases of AML. Does AML with reactive plasmacytosis also qualify as a separate entity in the classification of AML? Microscopic examination of the stained smear of BM from a patient of AML with reactive plasmascytosis has distinctively identifiable features comprising of blasts cells and conspicuously increased plasma cells. However no unique clinical, phenotypic, cytogenetic, molecular and biologic properties have been identified to merit its classification as a homogenous separate entity. Conclusion AML with plasmacytosis is a heterogenous phenomenon. Reactive plasmacytosis in AML must be differentiated from AML with MM as the latter requires different therapeutic approach. REFERENCES 1. Rangan A, Arora B, Rangan P, Dadu T. Florid plasmacytosis in a case of acute myeloid leukemia: a diagnostic dilemma. Indian J Med Paediatr Oncol. 2010; 31: 36‐8. 2. Rosenthal NS, Farhi DC. Reactive plasmacytosis and lymphocytosis in acute myeloid leukaemia. Hematology Pathology. 1994; 8: 43‐51. Table: Causes of AML with plasmacytosis AML= Acute myeloid leukaemia, IL= Interleukin, MM=Mul�ple myeloma Fig 1: Bone marrow aspirate and trephine showing blast cells and plasma cells indicated by white arrows and black arrows respec�vely (Magnifica�on: 40x). presence of a monoclonal band on serum protein electrophoresis, serum free light chain assay, and whole body magnetic resonance imaging (MRI) for bone lesions, help in the diagnosis of a concomitant MM. Our patient did not have any bony lytic lesions, Bence Jones proteinuria, or a monoclonal para‐ protein band. Serum free light chain assay was required to rule out myeloma with more certainty but not done due to non availability. Hence our diagnosis of AML with reactive plasmacytosis was JIIMC 2016 Vol. 11, No.4 AML with Plasmacytosis 190 3. Al Shughair N, Al Dawsari G, Gyger M, Mohamed G, Roberts G. Clinical significance of plasmacytosis in the day+14 bone marrow of patients with acute myeloid leukaemia undergoing induction chemotherapy. J ClinPathol. 2007; 60: 520–3. 4. Mailankody S, Pfeiffer RM, Kristinsson SY, Korde N, Bjorkholm M, Goldin LR, et al. Risk of acute myeloid leukemia and myelodysplastic syndromes following multiple myeloma and its precursor disease (MGUS). Blood . 2011; 118: 4086‐92. 5. Wei A, Juneja S. Bone marrow immunohistology of plasma cell neoplasms. J ClinPathol. 2003; 56: 406‐11. 6. Hyun BH, Kwa D, Gabaldon H, Ashton JK. Reactive plasmacytic lesions of the bone marrow.Am J ClinPathol. 1976; 65: 921‐8. 7. Wulf GG, Jahns Streubel G, Hemmerlein B, Bonnekessen K, Wörmann B, Hiddemann W. Plasmacytosis in acute myeloid leukemia: two cases of plasmacytosis and increased IL‐6 production in AML blast cells. Ann Hematol. 1998; 76: 273‐ 7. JIIMC 2016 Vol. 11, No.4 AML with Plasmacytosis 191 Page 51 Page 52 Page 53