T-Cell Acute Lymphoblastic Leukemia and Mediastinal Mass

A 19-year-old man was admitted to the hospital with malaise, fatigue, and intermittent fever (temperature of 38°C [100.4°F]) for the last 2 weeks. Physical examination revealed scarce purpuric lesions over the lower extremities; a pericardial friction rub was audible over the precordium when the patient was supine and seated, and the spleen was remarkably enlarged.

Laboratory findings indicated leukocytosis, anemia, and thrombocytopenia: the white blood cell count was 68,000/mL, with 90% blastocytes; the hematocrit was 27%; and the platelet count was 42,000/mL. Biochemical parameters were within normal limits, except for increased serum lactate dehydrogenase concentration, 2,800 U/L (upper normal limit, 450 U/L). An ECG showed sinoatrial tachycardia. The chest film, seen here, revealed a broadened mediastinum and a retrosternal mass. Ultrasonography disclosed a small pericardial effusion. These findings were confirmed by a CT scan.

Drs Haralampos J. Milionis, George Vartholomatos, and Moses S. Elisaf of Ioannina, Greece, add that a bone marrow specimen showed 85% blastocytes, and serologic markers for hepatitis B and C viruses, HIV, cytomegalovirus, Epstein-Barr virus, and human T-lymphotropic virus I and II infections were negative. The diagnosis of T-cell acute lymphoblastic leukemia (stage II) was established.

The patient was treated initially with intrathecal methotrexate, idarubicin, vincristine, and prednisolone intravenously. Seven days after treatment began, the mediastinal mass disappeared and pericardial effusion was minimal.