Initial presentation of leukemia as facial palsy in a 6-yr-o
Facial palsy due to granulocytic sarcoma in the temporal bone as the first presentation of acute myeloid leukemia (AML) is rare. Diagnosis of leukemia at first may be difficult as blast cells may appear in blood after an interval of weeks to months of initial presentation. The following case has been presented in the Indian Journal of Medical and Paediatric Oncology.

A 6-year-old boy reported with sudden onset right side facial weakness and facial asymmetry for 2 months. The patient had received a course of oral steroids without any improvement in facial asymmetry. He had a history of common cold and bilateral ear ache preceding the facial weakness. At presentation, he had right-sided House-Brackmann grade 4, lower motor neuron type facial palsy. Ear examination showed right-sided dull tympanic membrane with some bulge in posterosuperior quadrant and left-sided dull pars tensa.

Tuning fork test suggested bilateral conductive hearing loss which was more on the right side. Rest of the nose, throat and neck examination was insignificant. All blood investigations were normal including peripheral blood smear. High-resolution computed tomography (HRCT) of temporal bone showed soft-tissue density in middle ear, attic, aditus, and mastoid air cells with intact ossicles suggestive of bilateral mastoiditis. Hence, a provisional diagnosis of right-sided subacute otitis media with mastoiditis and facial palsy was made.

The patient was started on parenteral antibiotics and was taken up for mastoid exploration. Intraoperatively periantral cells, antrum, aditus, and attic were filled with granulations and pale, soft yellowish globular tissue which was sent for histopathology. All ossicles were intact and mobile. The aditus was made patent by removing incus and hypertrophic mucosa. Middle ear mucosa was hypertrophic. The Fallopian canal More Details was intact throughout.

Cortical mastoidectomy was performed, and the patient was given oral antibiotics for another week. Facial nerve palsy improved to grade 2 after 3 weeks following surgery. Histopathology of the sent soft tissue revealed many immature cells (blasts admixed with eosinophils and eosinophils precursors) which were immunopositive for CD34, MPO, and Tdt (focal) while negative for CD3, CD20, CD1a, and langerin.

The overall picture suggested infiltration by leukemic blast cells. As peripheral smear was normal, a bone marrow aspiration was performed which showed t(8:21) along with 7% blast cells. Hence, a diagnosis is made and patient started on chemotherapy. His facial weakness resolved completely during chemotherapy.

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Dr. H●●●●b .
Dr. H●●●●b . Oncology
Loved it! To the point & easy to comprehend. Thanks
Nov 19, 2018Like1