Extensive Bone Marrow Necrosis and Osteolytic Lesions in a Case of Acute Myeloid Leukemia Transformed from Polycythemia Vera

Abstract

Acute myeloid leukemia (AML) is the most common leukemia in adults. In rare cases, bone marrow necrosis (BMN) and osteolytic lesions are presenting features of AML. The following case describes a patient with known polycythemia vera (PV) that presented with signs of multiple myeloma, including hypercalcemia, anemia, and lytic lesions of the thoracic spine and skull. Laboratory workup was not indicative of myeloma. A bone marrow biopsy was performed, which revealed extensive BMN and initial pathology was consistent with metastatic carcinoma. However, no immunohistochemical stains could be performed due to the extent of BMN; a repeat biopsy was therefore performed. Flow cytometry and CD45 staining were consistent with PV that had transformed to AML. Due to the patient's comorbidities, she was a poor candidate for stem cell transplant and did not wish to pursue chemotherapy. Ultimately, she pursued hospice care. Based on our literature review, both BMN and osteolytic lesions are rare manifestations of AML and have not been reported to occur simultaneously. These findings can lead to a diagnostic dilemma and suspicion of other malignancies. This case demonstrates that AML should remain in the differential diagnosis in those patients who present with BMN and osteolytic lesions.

Keywords: granulocytic; leukemia; marrow; myelofibrosis; myeloid; myeloma; necrosis; osteolytic; polycythemia; sarcoma.

Figure 1. AP view of the skull on CT scan revealing a diffuse heterogeneous appearance of the marrow with scattered lytic lesions.

Figure 2. Sagittal view of the skull on CT scan revealing a diffuse heterogeneous appearance of the marrow with scattered lytic lesions.

Figure 3. Biopsy of the iliac crest revealing extensive bone marrow necrosis (H&E, 4X magnification).

Figure 4. Biopsy of iliac crest revealing extensive bone marrow necrosis (H&E, 40X magnification).

Figure 5. Biopsy of the T2 vertebral body revealing bone marrow necrosis and a focus of viable tumor cells (H&E, 4X magnification).

Figure 6. Biopsy of the T2 vertebral body revealing bone marrow necrosis and a focus of viable tumor cells (CD45 staining, 10X magnification).