Bullous Pyoderma Gangrenosum as the Presenting Sign of Acute Myeloid Leukemia in a Child

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A 10-year-old female patient was referred to our clinic with complaints of fever persisting for longer than 2 weeks, erythema, and tenderness on dorsum of feet for 2 days. Complete blood count was normal except for anemia (hemoglobin: 10.3 g/dL, white blood cell count: 17,000/mm3, platelet count: 221,000/mm3). An increase in acute phase reactants (sedimentation rate: 77 mm/saat and C-reactive protein: 10.1 g/dL [normal range: 0 to 0.8]) and atypical cells on peripheral blood smear were noticed. Tests done to search for prolonged fever and arthritis (blood antistreptolysin level, complement C3, C4 levels, antinuclear antikor, anti-ds DNA, blood angiotensin converting enzyme level), biochemical analysis of blood and posteroanterior chest radiography were normal. One day after hospitalization a bullous lesion with bloody elements inside, on right upper surface of right foot at the metatarsophalangeal joint level was noticed. Doppler ultrasonography of the lower extremities was normal. Magnetic resonance imaging of right foot revealed cellulitis. Throat culture, aerob, anaerob, fungal culture results of the blood, liquid and skin biopsy cultures taken from bullous lesion were all negative. Blood aspergillus antigen level (0.11 TU/mL, normal range: 0 to 0.5) was normal. Pathology result of skin biopsy revealed inflammatory cell infiltration within the entire dermis without malign cell infiltration. Factor V Leiden, Prothrombin, MTHFR (677), MTHFR (1298) mutation analysis were found normal but the patient was found homozygote mutant to plasminogen activator inhibitor 4G/4G. We examined peripheral blood smear and we did bone marrow aspiration and biopsy.
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