30 3 Vol. 30, No. 3, Sep.

, 2010

Case Report

A Case of Patient with Chronic Myelomonocytic Leukemia Presenting as Hypereosinophilia

Jin Wook Park1, Yi Rang Kim1, Soo Young Na1, Tai Sun Park1, Yun-Jeong Bae2, You Sook Cho2, Hee-Bom Moon2 and Tae-Bum Kim2
2

Division of Allergy and Clinical Immunology, 1Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

, , , . (chronic myelomonocytic leukemia, CMML) 1,000/L , 20% , 1

. 1 . (Korean

J Asthma Allergy Clin Immunol 2010;30:237-240)

Key words: Chronic myelomonocytic leukemia,Eosinophilia, Trisomy 8

blood or bone marrow (BM), and dysplasia in one or more myeloid

INTRODUCTION
Peripheral eosinophilia can be found in many medical settings, including drug reaction, infections, allergic diseases, collagen vas1) cular diseases, and hematologic malignancies. It can be divided into

lineages.3) It is known that t(5;12) creates a chimeric ETV6platelet-derived growth-factor beta receptor (PDGFRB) which is associated with eosinophilia in CMML.
4-7)

Other previously reported

gene abnormalities associated with eosinophilia in CMML are the FIP1L1-PDGFRA fusion gene (4q12) and pericentric inversion of chromosome 16.
7-9)

categories of primary and secondary eosinophilia, and primary eosinophilia is classified into clonal and idiopathic origin. Clonal eosinophilia can be accompanied by hematologic malignancies, including acute myeloid leukemia (AML), acute lymphocytic leukemia (ALL), chronic myeloid leukemia (CML), myelodysplastic syndrome (MDS), chronic eosinophilic leukemia (CEL), systemic mastocytosis (SM), and chronic myelomonocytic leukemia (CMML).
1) 1)

Although several cytogenetic abnormalities

4-9)

associated with eosinophilia in CMML have been reported,

trisomy 8 has been rarely reported. Hematologic malignancies are rare causes of eosinophilia, and clonal bone marrow disorders account for less than 1% of eosinophilia. as severe eosinophilia.
10)

We describe an unusual case of CMML with trisomy 8 presenting

CMML is categorized as a MDS by the French- American-British (FAB) classification and as myelodysplastic syndrome/myeloproliferative neoplasm (MDS/MPN) by World Health Organization
2) (WHO) classification. The MDS/MPN includes disorders where

CASE REPORT
A 71-year old man with a past medical history of diabetes mellitus visited our hospital for evaluation of exertional chest pain. He was diagnosed as mild coronary artery disease by coronary angiography, and treated medically. A complete blood count (CBC)
3 3 on admission revealed a WBC of 24.410 /mm , hemoglobin 10.5 3 3 g/dL, and platelets 29710 /mm . The differential counts of WBC

both dysplastic and proliferative feature co-exist. Due to the heterogeneous clinical and morphological features in CMML, its diagnosis and the prediction of biological behavior is not straightforward. CMML is characterized by persistent peripheral blood monocytosis greater than 1,000/L, fewer than 20% blasts in the

were 38% neutrophils, 10% lymphocytes, 15% monocytes, and

CorrespondenceTae-Bum Kim, Division of Allergy and Clinical Immunology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap 2-dong, Songpa-gu, Seoul 138-736, Korea Tel: 82-2-3010-3287, Fax: 82-2-3010-3287, E-mail: allergy@medimail. co.kr Received October 8, 2009, Revised October 16, 2009, Accepted October 20, 2009

37% eosinophils, and neither blasts nor dysplastic granulocytes were noted on a peripheral blood smear. The total serum Ig E level was 33.3 IU/mL. The patient was referred to the Department of Allergy to determine the cause of the eosinophilia. He did not complain of

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any other symptoms and took no medication except for hypoglycemic agents. Neither skin rash nor splenomegaly was observed upon physical examination at that time. We performed serologic tests for parasites including cysticercus, sparganum, clonorchis, and paragonimus, but found no abnormalities. The patient was followed up for further evaluation of eosinophilia, because he was considered to have idiopathic hypereosinophilia. Another CBC, conducted 2 months later, showed a WBC of 96.810 /mm , hemoglobin 11.4
3 3 g/dL, and platelets 16110 /mm . The differential counts of WBC 3 3

(FISH) assays using FIP1L1-Chic2-PDGFRA (4q12) DNA probe (Kreatech Diagnostics, Amsterdam, Netherlands) and PDGFRB (5q33) DNA probe (Kreatech Diagnostics, Amsterdam, Netherlands) were performed to study the PDGFRA and PDGFRB rearrangement, respectively. Neither PDGFRA nor PDGFRB rearrangement was noted. The patient was treated with hydroxyurea and his eosinophilia gradually improved in about one month.

showed 1% myelocytes, 2% band-form neutrophils, 53% segmented neutrophils, 3% lymphocytes, 25% monocytes, and 15% eosinophils; and 1% atypical lymphocytes were noted on the peripheral blood smear. We carried out a bone marrow (BM) examination to rule out hematologic malignancies. BM aspirate smears (Fig. 1) showed eosinophilic hyperplasia and differential counts of 2.8% myeloblasts, 2.2% promyelocytes, 14.0% myelocytes, 3.0% metamyelocytes, 5.6% band forms, 43.4% segemented forms, 1.4% immature lymphocytes, 4.6% lymphocytes, 4.0% promonocytes, 2.0% monocytes 6.4% normoblasts, and 10.2% eosinophils. The BM biopsy showed 95% cellularity with increasing granulocytic and monohistiocytic series. The patient was diagnosed as CMML. The karyotypes (Fig. 2) in metaphase analysis (Giemsa banding) of BM cells revealed 47, XY, +8[18]/46, XY[2]. Nested reverse transcriptase polymerase chain reaction was performed on BM samples to study major and minor BCR/ABL rearrangement, but revealed no rearrangement. The dual-color split fluorescent in situ hybridization

DISCUSSION
Eosinophilia can be accompanied by a variety of reactive conditions and clonal disorders, including infectious, allergic, collagen vascular, and neoplastic diseases, and the severity of associated diseases can range from self-limited conditions to life- threatening disorders.
1,10)

Recent advances permit a more logical approach to

diagnosis of patients with eosinophilia. A thorough patient history is the most important part of the evaluation for blood eosinophilia, and it should guide the extent and type of laboratory tests performed. Initial evaluation for eosinophilia includes a detailed history, including medications, travel history, and allergic symptoms, thorough physical examination, X-ray of chest, complete blood count with differential count, complete serum chemistry, Ig E, and stool tests.
1,11,12)

The specific studies required to rule out

other etiologies differ depending on findings from a thorough history, physical examination, and these studies. In most cases an underlying cause is known after such studies,
11)

but if the eosino-

Fig. 1. Bone marrow aspirate shows eosinophilic hyperplasia and increased monocytic series.

Fig. 2. Giemsa-banded karyotype of bone marrow cells shows 47,XY,+8.