Abstract :
A 65-year-old male patient was referred to our hospital with complaints of fever, weight loss and joint pains for the past 2½ years. He had also noticed extensive skin lesions over his knees, elbows and buttocks, which had developed during the last 4 months of his illness. Detailed examination and investigations found that he was suffering with chronic myeloid leukemia (CML). Physical examination revealed an enlarged spleen, which was palpable 18 centimeters below the costal margin. There was no lymphadenopathy. Skin examination showed well-demarcated and prominent shiny multiple firm whitish dermal nodules on the elbows, knees and larger lesions over the buttocks. The overlying skin, especially over the buttocks, was hard and tender, making it difficult for the patient to sit for a long stretch of time (Figures 1, ,2).2). The lesions over the knees and elbows were also tender. Before reporting to us on two previous occasions large amounts of calcified material were surgically extruded from the lesions over the buttocks, which resulted in partial resolution and temporary relief. Laboratory tests on admission showed Hb 8.7g/dL (normal, 14–18g/dL), and WBC 48 × 109/L (normal, 4.0–11.0 × 109/L). The differential count showed 50% segmented neutrophils, 3% band forms, 6% metamyelocytes, 12% myelocytes, 3% promyelocytes, and 3% nucleated RBCs. The number of eosinophils and basophils was also increased. The platelet count was 189 × 109/L (normal, 150–350 × 109/L). Leukocyte alkaline phosphatase was 0, urea 6 mmol/L (normal, 3.6–7.1 mmol/L), and creatinine 100 μmol/L (normal,<133 μmol/L). LDH was 800 IU/L (normal, <480 IU/L) calcium was 3.7 μmol/L (normal, 2.2–2.7 μmol/L), phosphorus 1.4 mmol/L (normal, 1.0–1.5 mmol/L). Parathyroid hormone level was 18 ng/L (normal, 10–55 ng/L). Bone marrow aspiration showed a hypercellular bone marrow and there was hyperplasia of the myeloid series and megakaryocytes. Skin biopsy taken from one of the lesions from the right buttock revealed granules and deposition of calcium salts in the dermis (Figure 3). The clinical condition of the patient remained stable for a short while after which he went into an accelerated phase. The complete blood count showed a hemoglobin of 8.1 g/dL, WBC 278 × 109/L with 8% myeloblasts. LDH was 1200 IU/L, blood urea was 28mmol/L, serum creatinine 250 μmol/L, calcium 5.4 mmol/L, albumin was 38 g/L (normal, 36–47 g/L) and phosphorous 1.8 mmol/L. The patient was treated with hydroxyurea initially for a 4-month period and later diuretics and steroids were added but the response was minimal.
