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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 5  |  Page : 940-942
Frank hematuria as the presentation feature of acute leukemia


1 Department of Accident and Emergency, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
2 Department of Medicine (Division of Hematology/Oncology), King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

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Date of Web Publication31-Aug-2010
 

   Abstract 

Muco-cutaneous bleeding is a common presenting feature of acute leukemias. Mucosal bleeding usually manifests as gum bleeding and/or epistaxis but may occur in any mucosal surface of the body. Hematuria as an isolated or main presenting feature of acute leukemia is rare. We describe two cases of acute leukemia, a 19 year old male with acute lymphoblastic leukemia and a 52 year old male with acute myeloid leukemia, both presenting with gross hematuria. There was no demonstrable leukemic infiltration of the urinary tract on imaging studies. Hematuria in these patients was likely to be due to occult leukemic infiltration of the urinary system, aggravated by thrombocytopenia, as it subsided after starting chemotherapy. Our cases highlight that hematuria should be remembered as a rare presenting feature of acute leukemia.

How to cite this article:
Suriya OM, Aleem A. Frank hematuria as the presentation feature of acute leukemia. Saudi J Kidney Dis Transpl 2010;21:940-2

How to cite this URL:
Suriya OM, Aleem A. Frank hematuria as the presentation feature of acute leukemia. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2017 Oct 20];21:940-2. Available from: http://www.sjkdt.org/text.asp?2010/21/5/940/68897

   Introduction Top


Patients with acute leukemia usually present with features of bone marrow failure and symp­toms and signs related to anemia, neutropenia and thrombocytopenia. More often there is a combination of these features. Thrombocyto­penia and platelet dysfunction in these patients results in skin and mucosal bleeding. Acute leukemia, particularly acute myeloid leukemia, can result in leukemic infiltration of many or­gans including urinary tract resulting in ma­nifestations like hematuria. [1] Clinically evident leukemic infiltration of the urinary tract is not common but significant percentage of patients have been shown to involve the urinary system in autopsy studies. [2],[3] Presentation of acute leu­kemia with gross hematuria is uncommon and this being the sole presenting feature is very rare and only few cases have been described in the literature. We present here two cases of acute leukemia, one with acute lymphoblastic leukemia and the second with acute myeloid leukemia with main presenting feature of hema­turia in previously healthy adults.


   Case Reports Top


Case 1

A 19 year old male presented with a two-day history of persistent frank hematuria and vague right flank pain. He had suffered from upper respiratory tract infection two weeks ago with uneventful recovery. There was no history of bleeding from any other site or orifices. His systemic review and physical examination were unremarkable.

The patient's Complete Blood Count (CBC) showed a hemoglobin level of 10.8 g/dL, mean corpuscular volume (MCV) 85.0 fl, White Blood Cell (WBC) count was 15.4 Χ 10 9 /L. Bioche­mical parameters including urea, creatinine and muscle enzymes were normal and Mid Stream Urine (MSU) revealed gross hematuria with too many red blood cells to obscure study for other parameters. The INR was 1.4 while APTT was normal. Examination of the blood film revealed the presence of blast cells.

An abdominal ultrasound suggested increased echogenisty of the kidneys. CT scan of abdo­men and pelvis was unremarkable and there was no evidence of a stone, tumor infiltration or anatomical abnormalities in the urinary tract. An intravenous urogram revealed no abnorma­lities.

Bone marrow examination showed infiltration of the marrow by 80% blasts. Cytochemistry of the bone marrow was consistent with a lym­phoid nature of the blasts. Immunophenotyping of the bone marrow blasts by flow cytometry was consistent with pre-B Acute Lymbhoblastic Leukaemia (ALL) and therefore the diagnosis of ALL was confirmed. Chromosomal analysis of the bone marrow was normal.

Hematuria improved with institution of hydra­tion and disappeared completely on the third day of chemotherapy. Chemotherapy was com­plicated by thrombocytopenia requiring frequent platelet transfusions. In spite of such low plate­let counts, hematuria never recurred. The pa­tient subsequently received consolidation che­motherapy after achieving remission, and is cu­rrently being evaluated for an allogeneic bone marrow transplantation.

Case 2

A 52 year old male presented to the emer­gency room complaining of bilateral loin pain, low grade fever and hematuria for the past seven days. He was not known to have any me­dical illness or bruising or bleeding from any other site. The patient was febrile (38 o C) and normotensive. His physical examination was un­remarkable except for the presence of pallor and mild bilateral loin tenderness. He was treated for urinary tract infection.

His hemoglobin level was 7.5 g/dL, MCV 105 fl, WBC count was 22.6 Χ 10 9 /L and the platelet count was 99 Χ 10 9 /L. Peripheral film revealed 24% blast cells with  Auer rods More Details. His liver func­tion test and coagulation profile were normal. Serum creatinine was 105 umol/L and blood urea 5.0 mmol/L. Mid stream urine examination showed +1 protein, +3 blood, 120 WBC/HPF and numerous red blood cells along with amor­phous deposits of crystals. An ultrasound of the kidneys and a CT scan of the abdomen revealed no abnormalities of the urinary tract. Hematuria subsided in few days; bone marrow aspirate and cytochemistry were consistent with the diag­nosis of Acute Myeloid Leukemia (AML) of M4 FAB subtype. The patient was started on induction chemotherapy and achieved remis­sion. He developed prolonged bone marrow ap­lasia after first consolidation chemotherapy and died of progressive fungal infection.


   Discussion Top


Acute leukemias are malignant disorders of immature hemopoietic cells characterized by infiltration of the bone marrow by abnormal and immature cells called blasts. [4],[5] Acute leuke­mias are divided into two main groups; Acute Myeloid Leukemia (AML) and Acute Lympho­blastic Leukemia (ALL). Most patients are symp­tomatic at the time of presentation due to bone marrow leukemic infiltration leading to bone marrow failure. This results in various cytope­nias and predispose the patients to bleeding, infections and features of anemia.

Bleeding in acute leukemias usually results from thrombocytopenia, involving the skin and mucus membranes and may or may not corre­late with the degree of thrombocytopenia as platelet dysfunction may also be present. Ano­ther cause of bleeding in some patients with AML is coagulopathy due to Disseminated In­travascular Coagulation (DIC), which is com­monly seen in patients with acute promyelo­cytic leukemia (APL). [6]

Hematuria as the only or main presenting fea­ture in acute leukemia is rare and has been reported occasionaly. [7],[8] Although any organ sys­tem in the body can be infiltrated by leukemia cells, urologic system is not commonly in­volved. When urinary tract is infiltrated by leukemia, kidney is the most common site of involvement. [2],[7] Leukemic infiltration of the uri­nary bladder is very rare, far rarer than that of the kidney and only 14 such cases have been reported. [8],[9],[10],[11] Although clinically evident involve­ment of the urologic system and hematuria are rare at presentation, leukemic infiltration was observed in more than 50% of cases in an autopsy study. [2]

We report here two cases of acute leukemia who initially presented with gross hematuria. In both of these patients there were no other signi­ficant symptoms and hematuria was the main presenting feature and they were initially thought to have primary urinary tract pathology. Leu­kemic infiltration of the urinary tract in our patients can not be ruled out. However, we were unable to identify any structural abnorma­lities or infiltration on multiple imaging inves­tigations. It is possible that cystoscopy and bladder biopsy and/or renal biopsy might have shown occult leukemic infiltration but these procedures were not done either due to patient refusal, risk of bleeding and/or lack of clinical indication.

The precise mechanism of hematuria in our patients remains to be elucidated. Although thrombocytopenia is the usual cause of bleeding in most of the patients with acute leukemia, bleeding due to occult urinary tract infiltration by the leukemia can not be ruled out in these patients. Since hematuria did not recur in both the patients after starting chemotherapy, despite the drop in platelet count to very low levels, the possibility of occult leukemic infiltration of uri­nary organs appears to be the likely cause of hematuria in our patients. The clearance of leu­kemic infiltration by chemotherapy possibly re­moved the focus of bleeding.

So in summary patients with acute leukemia may present with hematuria as the main symp­tom and this association should be kept in mind in this setting. We recommend performing a CBC, white cell differential, and in selected ca­ses with abnormal CBC, examination of the peripheral blood smear in patients who present with hematuria.

 
   References Top

1.Persky L, Newman AJ, Tucker AS. Urologic mani­festations of childhood leukemia. J Urol 1972;107: 1073-7.  Back to cited text no. 1  [PUBMED]    
2.Kirshbaum JD, Preuss FS. Leukemia: a clinical and pathologic study of one hundred and twenty-three fatal cases in a series of 14400 necropsies. Arch Intern Med 1943;71:777.  Back to cited text no. 2      
3.Vidana E, Bross ID, Pricken JW. An autopsy study of metastatic patterns of human leukemia. Oncology 1978;35:87-96.  Back to cited text no. 3      
4.Catovsky D, Hoffbrand AV (ed). Acute leukemia. In: Postgraduate haematology. Oxford: Butterworth­Heinemann. 1999;373-404.  Back to cited text no. 4      
5.Burns CP, Armitage JO, Frey AL, Dick FR, Jordan JE, Woolson RF. Analysis of the presenting features of adult acute leukemia: the French-American-British classification. Cancer 1981;47(10):2460-9.  Back to cited text no. 5      
6.Tallman MS, Kwaan HC: Reassessing the hemostatic disorder associated with acute promyelocytic leuke­mia. Blood 1992;79:543-53.  Back to cited text no. 6      
7.Watson EM, Sauer HR, Sadugor MG. Manifestations of the lymphoblastomas in the genito-urinary tract. J Urol 1949;61:626.  Back to cited text no. 7  [PUBMED]    
8.Chang CY, Chiou TJ, Hsieh YL, Cheng SN. Leu­kemic infiltration of the urinary bladder presenting as uncontrollable gross hematuria in a child with acute lymphoblastic leukemia. J Pediatr Hematol Oncol 2003;25:735-9.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Grooms AM, Morgan SK, Turner WR Jr. Hematuria and leukemic bladder infiltration. JAMA 1973;223 (2):193-4.  Back to cited text no. 9      
10.Troup CW, Thatcher G, Hodgson NB. Infiltrative lesion of the bladder presenting as gross hematuria in a child with leukemia: case report. J Urol 1972;107: 314-5.  Back to cited text no. 10  [PUBMED]    
11.Pentecost CJ, Pizzolato P. Involvement of the genito­urinary tract in leukemia. J Urol 1945;53:725.  Back to cited text no. 11      

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Correspondence Address:
Aamer Aleem
Associate Professor and Consultant Hematologist, Department of Medicine (38), King Khalid University Hospital, P.O. Box 7805, Riyadh 11461
Saudi Arabia
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PMID: 20814137

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