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ARTICLE
Year : 1968  |  Volume : 16  |  Issue : 2  |  Page : 81-84

Chloroma with autopsy reports


Medical College, Nagpur, India

Date of Web Publication22-Dec-2007

Correspondence Address:
P P Ahluwalia
Medical College, Nagpur
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Ahluwalia P P, Agrawal R V, Rawat M S, Kher A. Chloroma with autopsy reports. Indian J Ophthalmol 1968;16:81-4

How to cite this URL:
Ahluwalia P P, Agrawal R V, Rawat M S, Kher A. Chloroma with autopsy reports. Indian J Ophthalmol [serial online] 1968 [cited 2019 Dec 13];16:81-4. Available from: http://www.ijo.in/text.asp?1968/16/2/81/37500

Chloroma is a rare, usually myelo­blastic type of leukemia. It has the same relation to myeloid leukemia as malignant lymphoma has to lympha­tic leukemia. In its most characteris­tic form, it is associated with green­ish tumours which are usually sub­periosteal and are found especially in relation to the bones of the skull, par­ticularly of the orbit and thorax. No organ is exempt except perhaps the brain and spinal medulla (BRAN­NAN [1] . Kidney, liver, muscles and spinal meninges may be affected. The lymph glands and spleen though usually enlarged, are not always so. The pigment is believed to be proto­porphyrin (SCHULTZ AND SCH­WARTZ, [9] which has also been found in lymph glands from ordinary mye­loid lenkemia.

The malady appears most frequent­ly in young children and affects males twice as frequently as females (ED­GERTON) [4] . Leucocytic count is usually from 14,000/ c mm to 20,000/c. mm. In the early stage the total leucocyte count may be nor­mal. At this stage peripheral blood smear may reveal the immature cells (WINTROBE [10] )

Its aetiology is still unknown and has got always a fatal termination. Since its original description by BURNS [2] upto the year 1962, 342 cases (EDGERTON, [4] HA­MEED, TULSIDAS AND AGAR­WAL [6] ; and MORTADA [8] ), have been reported in the world litera­ture. The present paper deals with clinical and autopsy findings in a case of chloroma, in a young hindu male boy with bilateral proptosis as the main presenting symptom.


  Case report Top


A Hindu Male child, 3½ years of age was admitted with the complaints of gradual increase in the promi­nence of both eyes and ulceration of the left eye of 15 days and 8 days duration respectively. There was a past history of purulent discharge from both the ears.

On examination, the child was fully conscious, pale and afebrile. Pulse - 140 per minute, respiration normal. Preauricular, cervical and submandibular lymph noes were pal­pable, soft and discrete. The eye­lids were markedly swollen with pro­minent veins over its surface. The left eye had corneal ulceration [Figure - 1]. Funduscopy revealed bilateral papilloedema of less than one diopter with no other abnormality. Rest of the systems were normal.

Investigations:

Hoemoglobin was 50 per cent, total leucocytic count - 11,000/c mm. The leucocytic count differentiated poly­morphs 80 per cent and lymphocytes 20 per cent. X-ray of the orbits (antero-posterior and lateral views) and screening of the chest revealed nothing abnormal. Sickling and Mantoux tests were negative. Con­junctival smear was negative for pathogenic organisms.

The patient was given antibiotics, hypertonic glucose and local treat­ment for corneal ulcer. On the tenth day of admission, he was found to be more pale and optic atrophy was noticed to be commencing. On the 17th day, he had bleeding from the left ear. General condition was poor with marked emaciation. He was conscious, febrile and had no neck rigidity. Proptosis had increased and urticarial rash was seen all over the body. Spleen was 1 cm. palpable. Total leucocytic count was 20,000/c mm and in the peripheral smear plenty of immature blast series of cells were seen.

The patient continued in the same unsatisfactory condition for three weeks. On the 42nd day of his ad­mission he became apnoeic after tak­ing food and expired immediately, inspite of attempts at resuscitation.

Autopsy findings:

The body was that of a young, markedly pale and emaciated male child. The preauricular, submandi­bular, cervical, axillary, inguinal, bronchial and mesenteric lymph nodes were enlarged; they measured 1 to 2 cm. in diameter and were soft and discrete. On sectioning, they showed a greenish colour. Besides the lymph nodes, green colour tumour masses were seen in the liver and the kidneys [Figure - 2]. In the liver, the tumour was localised in the por­tal tracts. The spleen and lungs re­vealed greenish colouration, but no visible tumour mass.

The eyelids and paraorbital tissue on both sides had firm, green, irre­gular tumour masses. The eye balls were normal. In central nervous system, superior sagittal and both the lateral sinuses were occupied by a firm, homogenous thrombus [Figure - 3]. Green pus was aspirated from the right middle ear. Bacteriological cul­ture from the pus, thrombus and blood was positive for pneumococci.

Microscopically, the tumour in every organ was composed of cells with a prominent pale nucleus with nucleoli and indistinct cytoplasmic borders [Figure - 4],[Figure - 5]. These cells were seen infiltrating the superior sa­gittal and the lateral sinus wall with tumour thrombus in the lumen. The intestines and both the eyeballs show­ed microscopic infiltration. [Figure - 6].


  Discussion Top


Proptosis is the most common pre­senting symptom in cases of chloro­ma (MALKIN, [7] GOOD MAN AND IVERSON, [5] and DUKE-ELDER [3] . If the patient lives long enough, corneal damage, immo­bility of globe, papilloedema, retinal haemorhage, optic atrophy and blind­ness may result (DUKE-ELDER [3] ). The present case had bilateral proptosis as the presenting symptom. Bilateral papilloedema was recorded at a very early stage followed by corn mencing optic atrophy.

Leucocytic count was normal in the early stage in the present case. In the later stage, immature cells were seen in the peripheral blood. The chloroma cells were infiltrating the superior sagittal and lateral sinus walls with thrombus. The thrombus was not accompanied with any neu­rological symptoms.

Death is usually due to disturbance of metabolism, exhaustion, cerebral­myelitis, septiczernia or pneumonia (DUKE-ELDER, 1952). Our patient died due to septicemia and marasmus.


  Summary Top


Clinical and autopsy findings of a case of chloroma in a male child with bilateral proptosis as the main pre­senting symptom is reported.

In the terminal stage, the periphe­ral blood smear showed the presence of chloroma cells. In the post-mor­tem, green tumours were observed in the eyelids, both the orbits, lymph glands, liver, kidneys, lungs and spleen. Chloroma cells were also seen infiltrating the uveal tracts of the eye ball, intracranial sinus wall with tumour thrombus and the intestines. The patient died within two months of his first symptom due to septi­coemia and marasmus.

 
  References Top

1.
BRANNAN, D. (1926): Bull. Johns Hosp. Hosp. 38: 189.  Back to cited text no. 1
    
2.
BURNS, A.: (1827): Quoted by Ref. No. 3.  Back to cited text no. 2
    
3.
DUKE-ELDER (1952): Textbook of Ophthalmology, Vol. V. Lond., Henry Kimpton. p. 5556.  Back to cited text no. 3
    
4.
EDGERTON (1947): Trans. Amer. Ophthal. Soc. 45: 376.  Back to cited text no. 4
    
5.
GOODMAN C. G. AND INVERSON L.: Chloroma - A clinico-pathologic Study of Two Cases. Amer. J. Med. Sci. 211, 205, (1946).  Back to cited text no. 5
    
6.
HAMEED S., TULSI-DAS AND AGARWAL K. C.: Chloroma of the Orbit. Brit. J. Ophth. 43, 107 (1959).  Back to cited text no. 6
    
7.
MALKIN, B. M. (1925): Quoted by Ref. No. 3.  Back to cited text no. 7
    
8.
MORTADA, A. Orbital lymphoblasto­mas and acute leukemias in children. Amer. Jr. Ophthal. 55: 327, (1963).  Back to cited text no. 8
    
9.
SCHULTZ J. AND SCHWARTZ S.: The Chemistry of Experimental Chlo­roma II. Isolation of Crystalline Proto­porphyrin, Its Origin and Relation to Other Porphyrins. Cancer Research 16, 565, (1956).  Back to cited text no. 9
    
10.
WINTROBE, M. M. (1961): Clinical Hoematology. Philadelphia, Lea & Febiger.  Back to cited text no. 10
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6]



 

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