A 12 -year-old girl presented with a 2- to 3-month history of intermittent severe body pains, fatigue, and weight loss. A radiograph of her legs was normal. Laboratory tests showed normocytic anemia (hemoglobin, 8.7 g/dL), neutropenia (neutrophils, 0.966 × 109/L), 15% blasts, and normal platelet count. Bone marrow aspirate smears showed frequent medium-sized blasts with oval or folded nuclei, condensed nuclear chromatin, inconspicuous nucleoli, high nuclear-to-cytoplasmic ratio, and frequent salmon-colored granules (panels A-B, arrows; original magnification ×1000; Wright-Giemsa stain). Flow cytometry showed a large blast population expressing CD19, CD10, CD34, CD38, and TdT but no myelomonocytic or T-cell markers. Cytogenetic analysis showed an abnormal karyotype of 46,XX,add(1)(p21),add(7)(q11.2),-8,-13,-13,add(16)(q22),-21,+4mar[5]. Fluorescence in situ hybridization analysis revealed nuc ish (RUNX1x5-10)[70/200]. The diagnosis of B-lymphoblastic leukemia (B-ALL) with intrachromosomal amplification of chromosome 21 (iAMP21) was made. She was treated with chemotherapy per the high-risk B-ALL protocol (CCG 1961) and achieved complete remission at the end of induction. At her follow-up visit at 4 years off therapy, she was still doing well without relapse.

Salmon-colored granules are most commonly seen in acute myeloid leukemia with t(8;21)(q22;q22.1) RUNX1-RUNX1T1. They have not been reported in ALL. Their presence in this case might be related to RUNX1 abnormality.

A 12 -year-old girl presented with a 2- to 3-month history of intermittent severe body pains, fatigue, and weight loss. A radiograph of her legs was normal. Laboratory tests showed normocytic anemia (hemoglobin, 8.7 g/dL), neutropenia (neutrophils, 0.966 × 109/L), 15% blasts, and normal platelet count. Bone marrow aspirate smears showed frequent medium-sized blasts with oval or folded nuclei, condensed nuclear chromatin, inconspicuous nucleoli, high nuclear-to-cytoplasmic ratio, and frequent salmon-colored granules (panels A-B, arrows; original magnification ×1000; Wright-Giemsa stain). Flow cytometry showed a large blast population expressing CD19, CD10, CD34, CD38, and TdT but no myelomonocytic or T-cell markers. Cytogenetic analysis showed an abnormal karyotype of 46,XX,add(1)(p21),add(7)(q11.2),-8,-13,-13,add(16)(q22),-21,+4mar[5]. Fluorescence in situ hybridization analysis revealed nuc ish (RUNX1x5-10)[70/200]. The diagnosis of B-lymphoblastic leukemia (B-ALL) with intrachromosomal amplification of chromosome 21 (iAMP21) was made. She was treated with chemotherapy per the high-risk B-ALL protocol (CCG 1961) and achieved complete remission at the end of induction. At her follow-up visit at 4 years off therapy, she was still doing well without relapse.

Salmon-colored granules are most commonly seen in acute myeloid leukemia with t(8;21)(q22;q22.1) RUNX1-RUNX1T1. They have not been reported in ALL. Their presence in this case might be related to RUNX1 abnormality.

For additional images, visit the ASH Image Bank, a reference and teaching tool that is continually updated with new atlas and case study images. For more information, visit http://imagebank.hematology.org.