Acute myeloid leukemia (AML) is a heterogeneous clonal disorder characterized by immature myeloid cell proliferation and bone marrow failure. Over the years there have been several different classification systems for AML based on etiology, morphology, immune-phenotype and genetics. In the 1970s, AML was classified according to the French-American-British classification system using mainly morphology and immune-phenotype/cytochemical criteria to define eight major AML subtypes (FAB M0 to M7) .

The incidence of AML in adults is 5 to 8/100,000 per year in Europe, it increases with age, especially after 50 years. The mortality rate is 4 to 6/1,00,000/- per year. The median age of diagnosis is 65 years.

The diagnosis of AML requires examination of blood and medullary smears by trained cytologist. Cytogenetic study of the marrow (karyotype and in situ hybridization in FISH fluorescence) and a study in molecular biology (gene rearrangements resulting from abnormalities chromosome). We diagnosed a case of AML in a 36 year old patient, revealed by acute pancreatitis, and we discuss it in the light of data from the literature.

36 years old women admitted at Medicine department, rural tertiary care institution Govt. Medical College Kangra at Tanda with complaints epigastric pain with vomiting for 4-5 days with no other significant history. On clinical examination found a dehydrated patient, blood pressure: 110/70 mmHg, abdominal examination revealed epigastric tenderness, no organomegaly. CVS, Respiratory system within normal limit and The neurological examination was normal eliminating a possibility of neuron-meningeal blastic infiltration.

The biochemical assessment showed lipase at 690 IU/1, Blood Sugar; 116mg/dl, urea: 26m g/dl, Creatinine: 0.82 mg Calcium: 8mg% Phosphorus: 3.2m/dl; Uric acid: 5.5mg/d, CRP: 114 mg/, LDH: 325 U/L , Total proteins: 6.3 g/dl and Albumin 3.0 gm/dl. Serology for HBV; HBC; CMV and HIV are negative; Syphilitic serology is also negative. Serology was negative for rickettetial and leptospirosis. The hemogramm showed: anemia at 8 g/dl, MVC 81 fl, Leukocytes 1.30 lac/ul and Platelats at 32,000/ul. Total bilirubin 1.65 mg/dl, SGOT/SGPT 298/223 IU/L, Alkaline phosphate 220 IU/L. The medullogram showed the presence of 59% of undifferentiated blasts and myeloblasts Figure 1 with the positivity of myeloperoxidase activity. The blood smear Figure 2 revealed the presence of circulating blasts estimated at 36%. (The immunophenotyping and flow cytometry study could not be carried out due to lack of facility. Abdominal ultrasound is suggestive of aute panreatitis Figure 3. Abdominal CT scan (performed after 48 hours of onset of symptomatology) also s/o acute pancreatitis.

In our patient acute pancreatitis (AP) was classified moderate according to the Ranson score. At the end of this assessment, the diagnosis of AP associated with AML was retained. The patient was managed with I/V fluids ,antibiotics and other symptomatic treatment is being given. Due to lack of further investigation like flow cytometry, immunophenotyping and for further management patient was referred to higher institution, PGIMER Chandigarh.

Figure 3

Acute pancreatitis due to AML is very rare. Main causes of Acute pancreatitis are [21] biliary calculi (approximately 40% of AP), Chronic and significant alcoholism (approximately 40%) .Rare Causes are malignant or benin tumors of pancreas, Postoperative, Endoscopic retrograde cholangio- pancreatography. Exceptional causes hypertirglyceridemia (>10 mmo1/1). Hypercalcemia regardless of cause, Drugs, Infectious (viral, bacterial, mycotic, parasitic) Autoimmune Pancreas divisum and idiopathic. In our case no such causes are found.

Acute pancreatitis is a common complication of gall bladder stones or chronic alcoholism and hypercalcemia .Cause of hyperkalemia may be multiple like primary or secondary lympho-proliferative syndromes. Pancreatic infiltration with leukemic cells is a rare manifestation of acute lymphoblastic leukemia (LAL) 1. Acute pancreatitis in LAL is either due to hypercalcemia or chemotherapy, but direct damage to the pancrease by leukemic cells is rarely observed. 2,3. But in our case all these causes were ruled out. The diagnosis of acute pancreatitis is based on the association of typical abdominal pain with an elevation of lipase and amylase above 3 times normal. Image were done for the diagnosis and severity (classification of Balthazard).

The incidence of AML with recurrent cytogenetic abnormalities decrease with age 4,5. The translocation t (8;21) is present in about 5% to 10% of all AML cases and 10% to 22% of AML 2 cases6,7,8. This is a translocation affecting chromosomes 8 and 21. In 75% of cases, there are other associated chromosomal abnormalities, the most common being the loss of a sexual chromosome, the interstitial deletion of the long arm of chromosome 9, and trisomy 8 9.

Several studies have concluded that t (8;21) tends to form at the myeloid cells 10 our patient, the diagnosis of acute pancreatitis associated with acute myeloid leukemia, but the severity of acute pancreatitis classified according to the Ranson Score.

But the question remains: is there a link between these two pathologies? In the rare cases of association between acute leukemia and acute pancreatitis (AP), it is either an acute lymphoblastic leukemia leading to a hypercalcaemia at the origin of the AP, which is not the case of our patient because serum calcium was within normal limit. Other causes like iatrogenic pancreatitis, post-drug pancreatitis or post-chemoth Serapy based on Cytarabine, or L-asparaginses 11 are also not present in our case. By interrogation; the lithiastic etiology was ruled out. Computer tomography scan of the abdomen revealed acute pancreatitis, no obstructive lesion.

Two causes are like to explain the etilogical origin of acute pancreatitis: a pancreatic infiltration by the leukemic cells, a rare but possible etiology, or an idiopathic origin.

Acute pancreatitis is a severe pathology due to its complications, and its association with acute myeloid leukemia has rarely been reported as site of leukemia. Extrramedullary myeloid tumor in AML is associated with crisis or leukemic transformation complications. Clinicians should entertain pancreatic extremedullaey AML when pancreatic enlargement develops during or after onset of AML.

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