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 Table of Contents  
LETTER TO THE EDITOR
Year : 2015  |  Volume : 4  |  Issue : 3  |  Page : 476-478

Auer rods in polymorphs in a case of acute myeloid leukemia


Department of Hematology, SGPGI, Lucknow, Uttar Pradesh, India

Date of Web Publication13-May-2015

Correspondence Address:
Khaliqur Rahman
Type IV/98, New Campus, SGPGI, Raebareli Road, Lucknow - 226 014, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0513.151958

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How to cite this article:
Singh MK, Gupta R, Surabhi K, Rahman K. Auer rods in polymorphs in a case of acute myeloid leukemia. Clin Cancer Investig J 2015;4:476-8

How to cite this URL:
Singh MK, Gupta R, Surabhi K, Rahman K. Auer rods in polymorphs in a case of acute myeloid leukemia. Clin Cancer Investig J [serial online] 2015 [cited 2019 Oct 13];4:476-8. Available from: http://www.ccij-online.org/text.asp?2015/4/3/476/151958

Sir,

Auer rods are crystalline inclusions, pathognomic of myeloid differentiation of the leukemic blasts. Their presence in maturing myeloid cells and monocytes is rare. They have primarily been described in patients with acute promyelocytic leukemia (APL) and other French-American-British (FAB) subtypes of acute myeloid leukemia (AML), namely AML- M1, M2 and M4. We would like to document a case of AML-M2 with eosinophilia, where numerous polymorphs showed presence of Auer rods.

A 10-year-old male, born of nonconsanguineous marriage, presented to us with high-grade fever, loss of appetite and generalized weakness of 10 day's duration. Physical examination revealed moderate pallor and presence of submandibular lymph node measuring approximately 2 cm in maximum dimension. Complete hemogram showed hemoglobin of 73 g/L, total leucocyte count of 10.3 × 10 9 /L, platelet count of 29 × 10 9 /L and smear examination revealed 16% blasts, some of which contained Auer rods. Bone marrow aspiration smears were cellular and showed approximately 53% blasts, along with maturing myeloid series of cells and 8% eosinophils. Auer rods were noted in some of the neutrophils and myelocytes [Figure 1]. In addition, significant dysplasia was noted in the mature myeloid cells in the form of Pseudo-Pelger-Huet anomaly and hypogranulation [Figure 1]. On flow cytometry, theses blasts were positive for CD34, CD117, HLA-DR, CD13, cMPO and also showed aberrant expression of CD19. Interestingly these cells were negative for CD33. Hence, a final diagnosis of AML with maturation (FAB AML-M2 with eosinophilia) was proposed. Conventional cytogenetics showed a normal male karyotype, however molecular analysis using reverse transcription-polymerase chain reaction revealed AML1-ETO, (t[8;21]) fusion product.
Figure 1: May-Grunwald-Giemsa stained bone marrow aspiration smear showing Auer rod in neutrophil; inset showing a hypogranular and hypolobated neutrophil and myelocyte containing Auer rod

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Auer bodies are rod-shaped crystalline inclusions formed of azurophilic granules, named after John Auer, though they were first recognized by Thomas McCrae. [1] Based on the electron microscopic finding way back in 1977, it was concluded that the formation of Auer rods is due to defects in the formation, aggregation, and concentration of the peroxidase granules in the leukemic blasts. [2] Auer rods in neutrophils are a rare finding and their presence in neutrophils is suggestive of nucleo-cytoplasmic asynchrony; where the nuclear maturation has occurred, however, the cytoplasmic granule content is similar to that of immature myeloid cells. [2] A brief review of the literature has shown 11 case reports [3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] where authors have documented the presence of Auer rods in neutrophils, myelocytes, and rarely in monocytes [Table 1]. Majority of these cases belonged to the FAB AML-M2 and M3 category though occasional cases of AML-M1 and myelodysplastic syndrome have also been reported. In cases of APL, it was observed by the authors that Auer rods positive neutrophils were increased in patients after remission induction in pre all-trans-retinoic acid era. [7]
Table 1: Brief summary of the cases documented in literature showing Auer rods, in cells other than blasts

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In the present case, Auer rods are found in neutrophils, and some of the neutrophils also showed Pseudo-Pelger-Huet anomaly and hypogranulation; features of dysplasia. Morphologically the index case belonged to FAB AML-M2 with eosinophilia category. Further on flow cytometry these blasts showed aberrant expression of CD19. Expression of CD19, bright co-expression of CD34 and dim/absent expression of CD33, have been shown to have high positive predictive value for t (8;21). [14]

Overall, in conclusion, the presence of Auer rods is supposed to be associated with a good prognosis. Their presence in neutrophils and cells other than blasts clearly point that these cells are part of a malignant clone; however; their role in long-term clinical implications and diagnostic significance is still unclear. Moreover, their presence is not associated with any specific cytogenetic abnormality.

 
  References Top

1.
Bain BJ. Auer rods or McCrae rods? Am J Hematol 2011;86:689.  Back to cited text no. 1
    
2.
Bainton DF, Friedlander LM, Shohet SB. Abnormalities in granule formation in acute myelogenous leukemia. Blood 1977;49:693-704.  Back to cited text no. 2
[PUBMED]    
3.
Davies AR, Schmitt RG. Auer rods in mature neutrophils. J Am Med Assoc 1968;203:895.  Back to cited text no. 3
    
4.
Stass SA, Lanham GR, Butler D, Williams DL, Peiper SC, Kalwinsky DK, et al. Auer rods in mature granulocytes: A unique morphologic feature of acute myelogenous leukemia with maturation. Am J Clin Pathol 1984;81:662-5.  Back to cited text no. 4
[PUBMED]    
5.
Kato M, Oshima Y, Koyanagi H, Suetake N, Shitara T, Kuribayashi T. A case of acute myeloblastic leukemia with Auer rods in mature neutrophils. Rinsho Ketsueki 1986;27:355-9.  Back to cited text no. 5
[PUBMED]    
6.
Kanoh T, Hashimoto S, Usui T, Uchino H. Auer rods in mature granulocytes and monocytes. Tohoku J Exp Med 1986;148:99-102.  Back to cited text no. 6
[PUBMED]    
7.
Ashihara E, Ohkawa K, Gotoh H, Oku N, Inaba T, Murakami S, et al. Auer rods-positive neutrophils observed at diagnosis increased after remission induction in patient with acute promyelocytic leukemia. Rinsho Ketsueki 1992;33:666-70.  Back to cited text no. 7
    
8.
Anand M, Ghara N, Singh S, Kumar R. Auer rods in myeloid neoplasms. Indian J Pathol Microbiol 2005;48:53-4.  Back to cited text no. 8
    
9.
Kallel C, Makni F, Bouzidi H, Hdiji S, Elloumi M, Souissi T, et al. Myelodysplastic syndrome/acute myeloid leukemia with t (8; 21) and bundle of Auer rods in neutrophils: An unusual hemopathy. Ann Biol Clin (Paris). 2005;63:429-32.  Back to cited text no. 9
    
10.
Dawson MA, Whitehead S. Mature neutrophils with multiple Auer rods: A rarity in normal karyotype acute myeloid leukaemia. Br J Haematol 2007;137:86.  Back to cited text no. 10
    
11.
Guérin E, Mahon FX, Lippert E. Bundles of Auer rods in blast cells and mature neutrophils in a non-promyelocytic acute myeloblastic leukaemia. Br J Haematol 2008;141:749.  Back to cited text no. 11
    
12.
Ohnishi H, Yoshino H, Yoneyama R, Ishii M, Watanabe T, Bessho F. Faggot formation in mature neutrophils and metamyelocytes in acute myeloid leukemia without maturation. Pediatr Hematol Oncol 2008;25:165-70.  Back to cited text no. 12
    
13.
Dmitrienko S, Vercauteren S. Auer rods in mature granulocytes of a patient with mixed lineage leukemia. Blood 2012;119:4348.  Back to cited text no. 13
    
14.
Ferrara F, Di Noto R, Annunziata M, Copia C, Lo Pardo C, Boccuni P, et al. Immunophenotypic analysis enables the correct prediction of t (8;21) in acute myeloid leukaemia. Br J Haematol 1998;102:444-8.  Back to cited text no. 14
    


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