![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.](https://ash.silverchair-cdn.com/ash/content_public/journal/blood/138/14/10.1182_blood.2021012013/4/m_bloodbld2021012013f1.png?Expires=1768705452&Signature=4IvYJ4yToMfmQJNMov2rZ6EgoSek6ByNuzST4qeoFk3bPMlqn0qEndyWaOF2I3xjZF5fx9boPQBKUZj-~Gzhr8gLfGbi6UV5UkaGbvK02tjGUmdjQQErBihSapOYPkyz1qE5D4HocrGCV3k52wYETZXyVOobAxnlDRZcjCnbMhyTzAzOv1u~-oh~D6jag96doaV5GA1js8NzU2FLe7k71MMxFNqxfmOyDwtIDD~TadNja3g441khzv4MUqhrk3fKefMMD8hjDSKtIETwz3L05EoVy3e7MyhklrUs3NqsaGhBVPbN8i7D6lL8gzwDoZ~fRbE7R34OtNiw4Se1RcAJpQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA)
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.
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![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.](https://ash.silverchair-cdn.com/ash/content_public/journal/blood/138/14/10.1182_blood.2021012013/4/m_bloodbld2021012013f1.png?Expires=1768705453&Signature=umdZ2~abmU5ywm--N-C5Sb-MgUB15V5BdVyyDsyIJ1wRDtTp7j40FENJtFrc5XCTNUE8SkpjOOmopSVwzhV9zIm4JedTrI-TZafqXtmqQoGl9i5~s9f1OJbpjn3lO9ckseIokp9P4hamvni-UktagYhRpe0GR1jWn~a3if8ZQx-qf5BXjOvFxqyGsaU3EQuPUueyLGehfK5hNA52bT7MehOEry6dSwXNt-N4g5YOa6P-G7AEHjXMoVngqWAyto90dtWJ9nSTbj7EWOwqmqvS8714dn~5~iSYyOg-X7TBouC5dwIKnWllDSGplfx~CyClmaI7qozNoQezODl1Ng3OHw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA)
