Severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) caused an epidemic of coronavirus disease 2019 (COVID‐19). First known in December 2019, it was confirmed a pandemic by the World Health Organization (WHO) on 11 March 2020 as it has rapidly extent over the world [1]. The standard test for COVID‐19 presents the reverse transcriptase polymerase chain reaction (RT‐PCR) to recognize viral RNA from clinical specimens [2]. COVID-19 is a rapid spreading pandemic with high mortality rate. Assessable hematologic deviations have been distinct in the first COVID-19 patient studies [3]. The hematopoietic system actions a thoughtful character in the notable hyperinflammation, mainly in severely ill patients [4]. Complete blood count (CBC) is a routine test throughout preliminary biological assessment of patients. CBC analyzers such as SYSMEX® (Sysmex Corporation, Kobe, Japan), make available a white blood cell (WBC) with differential count which exhibiting a sorting of WBCs founded on their morphology and their intracellular components. But, the abnormal leukocyte result is rechecked by peripheral blood smear (PBS) examination for reassessment. Herein, we report a COVID-19 positive patient with severe permanent leukopenia on CBC and blastoid cells on PBS who underwent bone marrow biopsy for rule out acute leukemia as first diagnosis.
A 39-year-old woman with no known medical history presented to the emergency department in Sina hospital affiliated with Tehran University of Medical Sciences with a 1-week history of fevers, chills, worsening shortness of breath, headache, and malaise. Upon entrance to the hospital, her vital signs included a temperature of 38° C, heart rate of 100 beats/min, respiratory rate of 28 breaths/min, and oxygen saturation of 90% on room air. She needed oxygen at 6 L/min via a nasal cannula when she was in the emergency department. The first chest x-ray revealed perihilar opacification. She had positive RT-PCR test for COVID-19 and was consequently admitted to the COVID-19 unit for controlling of acute hypoxemic respiratory failure and COVID-19. Laboratory data documented before this encounter included hemoglobin of 10.2 g/dL, red blood cells of 3.8x106/µL, platelet of 163x10³/µL, C-reactive protein of 36.8 mg/L, prothrombin time of 12.2, and a partial prothrombin time of 33.8. The patient’s leukocyte (1.5x10³/µL with differential count: 84% neutrophils and 16% lymphocytes) persistent decreased with immature and blastoid cells on PBS after remission of respiratory symptoms that was requested hematology consultation for her. Because, the patient had persistent leukopenia with suspicious immature and blastoid cells on PBS, she underwent bone marrow biopsy (BMB) and aspiration. Bone marrow aspiration showed shift to left in myeloid series with presentation of extensive immature myeloid series and had about 30% atypical cells which were suspicious to blast (Figure 1).
First, we considered atypical cells were blast and acute myeloid leukemia was main diagnosis. So, immunohistochemistry staining on bone marrow biopsy was done. But, CD34, C-Kit, and terminal deoxynucleotidyl transferase (TDT) were unremarkable (Figure 2).
Slides sent to expert hematologic center (Shariati hospital) for rule out leukemia. So, according to patient’s history, IHC staining, and result of consultation, viral hematologic effect was established. Base on the diagnosis, the patient received no chemotherapy. After 6 months of follow-up examinations, leukocyte count increased gradually and was 8.1x10³/µL.