A 46-year-old female patient with no past medical history of note. She presented to Emergency department (ED) complaining of headache for 3 days, she denied any other complaint. She was vitally stable and physical examination was unremarkable.
Investigation showed marked leukocytosis. CBC revealed: WBC: 81.3 × 109/L, HG:11.3 gm/dL, platelets: 1751 x 109/L, Neutrophils: 65 × 109/L, lymphocytes: 5.7 × 109/L. monocytes: 1.6 × 109/L, eosinophils: 1.6 × 109/L, basophils:0.81 × 109/L.
Peripheral smear reported marked neutrophil leukocytosis with marked shift to left, eosinophilia, basophilia and scanty circulating blasts. These findings are in keeping with myeloproliferative neoplasm, favoring CML.
Abdomen ultrasounds didn’t show hepatosplenomegaly or lymphadenopathy.
Bone marrow biopsy showed features consistent with CML BCR-ABL1 positive with morphological features of chronic phase.
At the time of diagnosis, patient had normal liver function tests (aspartate
aminotransferase (AST) 26 U/L, alanine aminotransferase
(ALT) 25 U/L, and total bilirubin 5 umol/L.
As part of screening before starting TKI, hepatitis serology was sent and it showed positive hepatitis B core antibody, positive hepatitis B surface antibody, negative HBV surface antigen, undetectable hepatitis B DNA, negative hepatitis C antibody and negative HIV test.
Patient was started on imatinib and entecavir. Follow up over the next 6 months showed good medication tolerance and normal liver function tests.