Case Report Highlights Rare Case of CML Presenting With Morel Lavallée Lesion

In patients with chronic myelogenous leukemia (CML), patients sometimes present with soft-tissue hematomas resulting from platelet dysfunction, acquired Von Willebrand disease, or acquired Glanzmann thrombasthenia. However, a new case report demonstrates that there can be other causes, including the rare Morel-Lavallée lesions (MLL).

Many patients with CML—about 40%—present without symptoms, explained the authors. When patients are symptomatic, the most common symptoms include fatigue, malaise, weight loss, abdominal fullness, and bleeding due to platelet dysfunction.

“On a few rare occasions, CML can present initially with soft-tissue hematoma,” they wrote in Clinical Case Reports. “This can be managed by treatment with tyrosine kinase inhibitors as well as conservative measures.”

In the case at the center of the new report, a 48-year-old male patient who had no history of chronic illness arrived in the emergency department reporting posterior chest wall pain and swelling, which he indicated had been a problem for about 2 weeks. The patient did not have fever, shortness of breath, or chest or abdominal pain, nor did he report dizziness, headaches, or night sweats. He did, however, state that he had lost about 7 kg in weight over the past few months.

A physical examination revealed a small cervical lymph node, massive splenomegaly, and a large mass in the patient’s left interscapular area, the study investigators said. The mass measured 13 x 10 cm. The patient’s lab results also included significant leukocytosis and anemia, and a peripheral smear suggested myeloproliferative neoplasm.

“He was started on intravenous hydration, allopurinol (Zyloprim), hydroxyurea, and supportive blood transfusions,” the authors said.

A bone marrow biopsy and a positive BCR-ABL1 test confirmed the physicians’ theory that the patient had CML.

Meanwhile, the authors used an ultrasound to investigate the patient’s swelling.

“Ultrasound of the chest wall mass showed sonographic findings of a large left infrascapular mass lesion suggestive of elastofibroma dorsi,” they explained. “However, due to the patient’s presentation, further evaluation by a contrast-enhanced chest CT was recommended.”

That CT scan showed a large chest wall lesion, which the investigators thought could be MLL, a closed traumatic soft-tissue degloving injury that occurs when the hypodermis separates from the underlying fascia, leading to intralayer buildup of hemo-lymphatic fluid. The investigators ordered a biopsy of the mass to rule out myeloid sarcoma, which showed necrotic debris and mixed inflammation.

The patient improved while hospitalized, and he was discharged with a prescription to take 100 mg of dasatinib (Sprycel) daily. Two weeks later, the patient reported significant improvement in his pain and the mass size had been reduced.

The investigators said this was only the second case of CML with MLL reported in the literature. The previous case was of a 16-year-old who had a knee lesion that was found to be an MLL. That patient eventually required surgery to manage the lesion, along with dasatinib. The patient in the new case report saw his lesion resolve completely without surgery.

“It is not clear why this patient developed such hematoma with no history of trauma, and in an unusual site like the chest wall, but spontaneous hematoma due to platelet dysfunction is a possible etiology in this case,” they wrote.

They concluded by pointing out that “it is important to keep in mind hematological malignancies as a possible cause of unexplained bleeding with soft tissue hematoma.”

Reference

Mohamed SSI, Qasim HM, Mahfouz A, et al. Chronic myelogenous leukemia presenting with Morel Lavallée lesion: a case report of a rare presentation. Clin Case Rep. 2022;10(12):e6807. doi:10.1002/ccr3.6807