Morphological Clues of Acute Monocytic Leukemia in COVID-19-Induced Transient Leukoerythroblastic Reaction with Monocytosis

Abstract

Viral infections, including those caused by COVID-19, can produce striking morphologic changes in peripheral blood. Distinguishing between reactive changes and abnormal morphology of monocytes remains particularly difficult, with low consensus rates reported amongst hematopathologists. Here, we report a patient who developed transient monocytosis of 11.06 × 10⁹/L with 32% promonocytes and 1% blasts during hospitalization that was secondary to severe COVID-19 infection. Three days later, the clinical status of the patient improved and the WBC had decreased to 8.47 × 10⁹/L with 2.2 × 10⁹/L monocytes. Flow cytometry studies did not reveal immunophenotypic findings specific for an overt malignant population. At no time during admission did the patient develop cytopenia(s), and she was discharged upon clinical improvement. However, the peripheral blood sample containing promonocytes was sent for molecular testing with an extended next-generation sequencing myeloid panel and was positive for pathogenic NPM1 Type A and DNMT3A R882H mutations. Subsequently, despite an essentially normal complete blood count, the patient underwent a bone marrow assessment that showed acute myeloid leukemia with 77% promonocytes. This case emphasizes the critical importance of a full work up to exclude acute leukemia when classical promonocyte morphology is encountered in the peripheral blood. Promonocytes are not a part of the reactive changes associated with COVID-19 and remain specific to myeloid neoplasia.

Keywords: COVID-19; acute myeloid leukemia; monocytes; promonocytes.

Figure 1

Clinical course and hematological lab values. (A) Graph depicting the patient’s clinical course and total leukocyte, neutrophil, lymphocyte, and monocyte counts. Admission to tertiary care is set as Day 0. (B) Graph depicting the patient’s clinical course along with hemoglobin and platelet counts.

Figure 2

Promonocyte morphology in peripheral blood and bone marrow. (A) Peripheral blood smear on admission showing classical promonocyte morphology. (B) Bone marrow aspirate (Wright-Giemsa stain) with a large number of promonocytes.