P145 | Persistent fever of unknown origin and bilinear cytopenia of new onset in healthy woman

P. Troia¹, M.G. Loffredo¹, F. Racca¹, R. Remollino¹, N. De Biase¹, G. Tancredi², G. Bini³, S. Mechelli³, C. Sonato³, M.G. Paladini³ | ¹Department of Clinical and Experimental Medicine, Internal Medicine Unit, University of Pisa, ²Department of Clinical and Experimental Medicine, Hematology Unit, University of Pisa, ³Department of Emergency and Urgent Care, Internal Medicine Unit, AOUP, Pisa, Italy

Premises: A 65-year-old woman was admitted for persisting fever, anaemia (Hb 9.7 g/dL) and thrombocytopenia (PLTs 52.000/mmc).
Discussion: Upon physical examination, a single leg skin ulcer and fever were found. Laboratory results showed leukocytosis, elevated CRP and procalcitonin, highly elevated ferritin (4700 µg/L) and methicillin-sensitive S. aureus bacteraemia. Antibiotic therapy with daptomycin and ceftriaxone was promptly started. A full body CT-scan and transoesophageal echocardiography were performed, negative for infectious diseases. Despite antibiotic therapy and after all subsequent blood cultures came back negative, the patient’s clinical conditions began rapidly deteriorating and the skin ulcer widened, while inflammatory biomarkers remained elevated, leading to suspecting pyoderma gangrenosum associated with a haematological disease. Therefore, bone marrow biopsy was performed, showing 15% marrow blasts and a mutation in the NPM1 gene, consistent with a diagnosis of acute myeloid leukaemia (AML). In the absence of viable alternatives, the patient was started on steroids and azacitidine, which had been initially withheld due to the concern of concomitant sepsis. This led to swift remission of fever and complete normalization of inflammatory biomarkers, and the patient was discharged shortly after.
Conclusions: Skin ulcer associated with deregulated inflammation allowed for correct diagnosis of AML and subsequent therapeutic decision making in this patient.