![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=1735617251&Signature=45NLLJlUhO2ANM810uTNtuYZmbriPSLvGOzun8wTID~3DN6TufYYPmNOudiHPmvJSHcbVS3L~61NSC3sH5~jv9E~5MyXT91-59w~MhY6dzAivIV28rGMa6rRKP4C2lfbKFlkAjuSYq7EPhhzi1j0yBgnRI2nwSFjCP4SUeEojD3AnH1NTvgTXqvIN7-FBvTgzreX1WtM2jpe9rJeFZgwRz8tenr2uT-P8TZP7B~6i6S3OOyn3K1cNSM8z41G5cln-0XPk7PPsY~UkgnY4nyfLlxaPY5Fyar7og7v02qrmyrlHA~zkDVigO9e2edPBi-qC39F75rHj5YwvGk9~w54zA__&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=1735617252&Signature=tFMIwTIrklLI22W1ddVhNDEjS8hQOUwIHzs4t-~40A9zpvIGIeIOpxzO3p4XLBWfLGkDN0jEtxS9Rx94JBsx1cMQrVSLb51QhKBMrBirdTnjY-w75yE3bXqvT0X14vxd6Ndh7HNxyVdZlMOm0XqtjKeqV0yIVqy1Dar3ZOCo-pOWeTDgjWStt~gxJD6tKKYhlwzSRqeoIcz4YlRfI4fxyMh5Au8euBcTnsZbnYvalEPgBVRCI3D~usCeluYU5hWy7u--uaUHfXBmSfvQLD4KhT2bivPwDDJ1m9AlPHiZu0vvq6VDHc65twaHWN7pnBCfo5KNBO1EgYXMT7Ku6ttg~A__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA)
