Acute transformation of chronic-type adult T-cell leukemia/lymphoma presenting with seizures.

Adult T-cell leukemia/lymphoma (ATLL) is a peripheral T-cell neoplasm caused by human T-cell lymphotropic virusI (HTLV-I). ATLL is classified into four clinical subtypes, including two aggressive (acute and lymphoma) and two indolent types (chronic and smoldering). Herein, we report the case of a Taiwanese patient with acute transformation of chronic ATLL presenting with seizures. In February 2013, a 68-year-old man was brought to the emergency room after a generalized convulsion for 10 minutes and conscious loss. There was no fever or skin rash. His major diseases included recurrent urothelial carcinoma of the urinary bladder, pneumonia with respiratory failure, and diabetes mellitus. He was diagnosed with chronic-type ATLL in September 2012. At that time his hemogram showed the following measurements: white blood cell (WBC) count of 13,400/mL with 39% lymphocytes and some abnormal cells with irregular nuclear contours (Figure 1A), and hemoglobin level of 11.2 mg/dL (anemic). However, his platelet count was normal. His laboratory data were as follows: albumin level, 2.1 g/dL (lower than normal); blood urea nitrogen (BUN), 34 mg/dL (elevated from the normal level), elevated lactate dehydrogenase (LDH), normal calcium level, and positive anti-HTLV-I/II. Abdominal computed tomography was negative for hepatosplenomegaly or lymphadenopathy. Flow cytometry immunophenotyping showed that 70% of the lymphocytes were T cells expressing CD2, CD4, CD5, CD25, and T-cell receptor-a/b but not CD7 or CD8. These lymphocytes are clonal for TRG gene rearrangement. At this current admission, hemogram showed WBC at 42,900/mL with 21% lymphocytes characterized by markedly irregular nuclear contours (flower cells; Figures 1B and 1C) and anemia (hemoglobin at 12.7 mg/dL). His calcium level was slightly elevated. Magnetic resonance imaging of the