A 55-year-old woman, who was diagnosed as myelodysplastic syndrome, complained of double vision on lateral gaze at 34th hospital day. There was no history of pulmonary tuberculosis, hyppertension or diabetes mellitus. She never smoked or drank alcohol.
On admission, she showed a chronically ill-looking appearances. The vital signs were within normal range. On physical examination, she had slightly pale conjunctivae. Other physical examination did not show abnormal findings. Neurologic examination was negative.
Laboratory findings on admission showed that the white blood cell count was 28,000/mm3 with 2 percent blasts and 12 percent monocytes, the hemoglobin was 9.4gm/dL, the hematocrit was 28.6% and the platelet count was 21,000/mm3 (Fig. 1a). The cellularity of bone marrow was 90 percent with 17 percent blasts (Fig. 1b). A diagnosis of myelodysplastic syndrome and chronic myelomonocytic leukemia (CMML) was established and treatment was initiated with low dose cytosine-arabinoside.
One month later, she complained of double vision on both lateral gazes, especially, severe on the right. Magnetic resonance imaging (MRI) brain scan revealed small nodular density in the mid-brain (Fig. 3a). Cerebro-spinal fluid analysis was made. Cell morphologies were polymorphic and atypical monocytes and immature cells were seen (Fig. 2). The white blood cell count was 17,900/mm3 with 3 percent blasts and 16 percent monocytes, the hemoglobin level 7.5gm/dL, and platelet count 4,000/mm3. She was diagnosed as granulocytic sarcoma and treated with 2,520 cGy brain radiotherapy for 14 days. After radiotherapy, a follow-up magnetic resonance imaging brain scan revealed the disappearance of the lesion (Fig. 3b). Cerebro-spinal fluid cytology had returned to normal.
Five months later, she was rehospitalized with left side hemiplegia. Computed tomographic scan of the brain revealed 3x4cm sized, round, hyperdense masses with surrounding edema in the parenchyma of the brain (Fig. 3c). The white blood cell count at relapse was 86,100/mm3 with 5 percent blasts and 9 percent monocytes, the hemoglobin was 9.1gm/dL and the platelet count was 12,000/mm3. She was managed with conservative treatments, because of poor performance status, and died 6 month after diagnosis of granulocytic sarcoma.