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Cholecystitis as the initial presentation of acute myeloid leukaemia

A 52-year-old man with no past medical history presented with a one-month history of right upper quadrant pain and postprandial discomfort. Physical examination was notable for right upper quadrant focal tenderness. A full blood count showed haemoglobin concentration 123 g/l, white cell count 5 2 9 10/l with a normal differential and platelet count 373 9 10/l. Alkaline phosphatase was elevated to 418 iu/l (reference range 30–126). Ultrasound of the abdomen showed a normal gallbladder with a small amount of sludge. A computed tomography (CT) scan of the abdomen showed focal thickening along the fundus of the gall bladder without biliary dilation. A diagnosis of chronic cholecystitis was made and the patient underwent an elective laparoscopic cholecystectomy. The gall bladder showed a bluish white infiltrate at the fundus giving it a cartilaginous texture. Histopathology showed a diffuse infiltrate of large cells with high mitotic activity and scanty cytoplasm (top left). Immunohistochemistry showed the neoplastic cells to be positive for myeloperoxidase and CD45 (top right and bottom left), consistent with a granulocytic sarcoma. A subsequent review of the peripheral blood film showed 75% segmented neutrophils, 1 5% metamyelocytes, 2 5% myelocytes, 12% lymphocytes, 6% monocytes, 2% eosinophils and 1% blasts. Bone marrow examination showed 14% myeloblasts (bottom right). The bone marrow findings in association with the granulocytic sarcoma indicated a diagnosis of acute myeloid leukaemia (AML). Cytogenetic analysis was normal. Surgical removal of the gall bladder was accepted as adequate local therapy and standard AML induction chemotherapy (cytarabine and daunorubicin) was initiated, but he had refractory disease requiring re-induction with high dose cytarabine and, ultimately, allogeneic stem cell transplantation. Granulocytic sarcoma is a rare neoplastic condition, characterized by infiltration of extramedullary tissues by immature myeloid cells. Rarely it is a presenting isolated manifestation of AML. Gall bladder involvement is extremely uncommon. The diagnosis can be made with adequate pathological evaluation that includes comprehensive immunohistochemistry. The discovery of a granulocytic sarcoma should always prompt an investigation for AML. This diagnosis can be made with less than 20% bone marrow blast cells when a granulocytic sarcoma is present.