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1951 6: 990-1001

Congenital Leukemia
WILLIAM G. BERNHARD, IRA GORE and RALPH A. KILBY

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From bloodjournal.hematologylibrary.org by guest on February 17, 2014. For personal use only.

Congenital
By
WILLIAM

Leukemia
M.D., A.
KILBY,

G.

BERNHARD,

IRA

GORE,

MI).

AND

C
factor
day reports

RALIH

I\I.D. undommon
in

ONGENITAL
a number of are

leukemia
well

is an the
aware

exeedingly
cases

(lisease,

yet

theie
that
P!csent

is
the s

authenticated

or factors
pathologists

which system. disorder

produce
keenly

leukemic
of the

the literatu!e ind!icating state may operate in utero.

lability of the

extraord!inary

infant

hematopoietic cases of this

are

As a consequence, are now- recognized

accurately classified

but than
as

somewhat paradoxically, in the past. Many of the

erythroblastosis fetalis,

fewer older

now

more

congenital

syphilis, acceptable these we Pathology

of each To
or

or
have

sepsis.
added

Table

1 lists as to
from

the the
the

14 cases presence
files of

in
the

the

literature state
Forces Armed

that at

presented! bi!th.
studly

documentation (table 2).

adedluat.e cases. the criteria of

of a leukemic examination had 1)een

there

To
of

4 cases

Institute duiing at with

In addition
hematologic congenital

to autopsy
studies leukemia,
or signs

and conducted
must

microscopic

the
of

tissues, these fulfill

life
birth

in

1)e manifest correlated

of

shortly

thereafter, hematologic

symptoms

which

can
ion

be

the

characteristic latter,

however,

may

disturbance. The iecognit be delayed as in Case 4 (AFIP

spontaneous

the
mucous

nature

234131).

Significant

of the physfever
showing usually
maiIOw

ical manifestations are: nodular skin infiltrations, and

an

enlargement should
of poorly

hemorrhages of spleen an alteration

of skin and! and livei, of the

membrane,

ad!enopathy,
marrow cells bone by

pallor.
undue

The
proportion

blood series; cases

of

reflect

the studies.

granulocytic In most.
numbers

differentiated oi undiffeientiated ideally there should be confirmatory

cells

of

considerable
red

reduced

and

elevation platelets

of the white blood arc also observed.

cell count Nucleated

and red

cells may be present. ically with leukemia

ieports of

regaro!ing

in varying number. Since changes easily confusedl pat hologoccur in congenital syphilis and ervthroblastosis fetalis, serologic studies on the mother should he available and information the possibility of blood group or type incompatibility between mothei should!
be

and Case
Case

infant Reports
1, AFIP

obtained.

Accession 280588.* A white, full term male infant, who lived for o!Ily 19 delivered without incident on August 18, 1948, at 2:11 P.M. The mother, aged 37, para 3, gravida 4, had been under observation for the last five and a half mo!lths of her pregnancy and had experienced an uncomplicated gestation. Serologic tests for syphilis had! been negative; the blood group was 0 type, Rh0 positive. The child arrived from the delivery room in a depressed state nineteen minutes after birth. He was lethargic an(l cyanotic; his ski!i was mottled; his facies mongoloid, isis liver palpable 5 cm. below the costal margin, antI there were (liffuse pulmonary rhonchi. Despite stimula!its and artificial

hours,

had

been

From

the

Armed

Forces

Institute

of

Pathology,

Washington,

8Case
N.J.

Submitted

Ja!iuary 1 (Ace. 280588)

16, 1951;

studied

accepted through

for publication the courtesy

April of Dr.

1). C. 3, 1951. Paul Russoma!lno,

Newark,

990

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WILLIAM

G.

BERNHARD,

IRA

GORE

AND

RALPH

A.

KILBY

991

respirat

iOti

110

i!nI)rovelne!it

twenty-four

hours

The
15.3 Gm.

re(I

1)100(1

or 93 p
aIi(I

svas !iote(l ; the temperature rose an(I the infant died less than after birth. cell count several hours before death ss-as 4,200,000 and the hemoglobin cent . Color index was I .1 , atid the red blood cells showed anisocytosis, and hyperchromia. White blood cell counts ranged between

poikilocytosis,

macrocytosis

246,5(X)

nucleated ret! blood cells. The corrected white blood (cli coulits with 65,000 and 63,000 nucleated red blood cells. In (lifferential counts nweloblasts niade UI) from 19 to 25 per cent; progranulocytes 4 to 8 per cent ; myelocytes, 12 to 16 PCF cent ; metamvelocytes, 14 to 22 per cent ; and segmented forms, 15 to 24 per cent.. There were numerous mature a!id immature eosinophilic forms. The infant.s re(! 1)100(1 cells containe(1 the Rh factor, Rh0 type. A iolops!j. A full term, newi)orn male, 52 cm. in length, weighing 3200 Gm., presented
niottle(I cetianeum; I)ertroPh !iOte(I. septum
(\ttIiOSIS of an otherwise unmarred

lSl,()0(), uncorrecte(1 for were 1S1,()0() a!id 90,700,

skill

surface.

There

was

moderate

caput

sue-

the

skull

was

brachycephalic;
tt!i(!
.

the partial and

facial
agenesis liver

features
and

were
deformity

typically
of

mongoloid.
the left ear

Hywere 35

The

of the left buccal area abdometi was l)rotul)eratit

.

In the slightly

enlarged
were

heart closure
was considereol

(25 Gm.)
enlarged,

the

interatrial
weighing

was virtually aI)se!it and 210 Gm., respectively. ligaments of the najor joints
Other filtrated findlings with granules, incluoling
examination.

The

spleen

considerably
shortening

The

skull exhibite(I premature were u!iusuallv lax, atid there

(iuctus arteriosus were

of the
within were

fontanelles;
of

both
normal

the humeri.
limits. in-

a patent

.Ificroscopic

i!lmature
and

cells
a mo(Ierate

The liver, spleeti, of the granulocytic

numi)er of had occurred ol)literated the cytologic pat cells Erythropoiesis A white and! which tern

lungs series.
it the normal unduly

and pancreas Maiiy of the

were liver where histologic homogeteous.

extensively

cells
present.

contained
in the leukemic The

eosinoliver and inbone of

1)hilic
sI)leeli. filtrate marrow poorly

megakaryocytes

The most. striking seemed almost. was hyperplastic

changes to have and! its

the intense components. Large series to a (lied at

numbers

differetitiated

portio!1
foci; with of the Case
acute

of the
megakaryocytes 2, AFIP

arid! hematopoietic were Accession

undifferentiated! tissue. sparse. 205756 leukemia, syndrome),

#{149}*

of the

granulocytic was reduced infant, talipes enlargement duration, studies Delivery who

formed the major few inconspicuous the heart. noteworthy age

female i)ilateral idiopathic was the 1948;

of 3 weeks
shortening The blood mother only for were infant were mass and

gratulocytic

prese!ite(!

varus, was of t.he

congenital of the

neck

(Klippel-Feil

was 25 years hydramnios

negative; the

of

age,

and

pregnancy,

of normal Serologic

during
mot.hers

the
at

terminal
1)100(1 birth, exami!1ation. cells

t.wo mo!it.hs.
contained 14, The in January

maternal

Rh
the

factor.

was already with

normal.
a large aspirated

The
round mucus an

weighed
apparent.

4,196
on

Gm.
physical

abnormalities was was protuberant

mentioned

abdome!3 breathing the

the left atelectasis

it heart shadow. ervthrocvtes cent,

upper quadrant.. Difficulty of t.he left lung.

exami l3lood nation counts total were as leukocvtes forms hemoglobin 21 per cent. and weight noted! with infatit, a1)sent; was cervical, cent.,

attributed
anti 17, 1948: forms

to

Roentgenoglogic

confirmed

at electasis January segmented!

demonstrated hemoglobin 35 per cent, cent, 5,200,000, total

enlarged cent, 4 p 1 per forms 30

5,900,000, 1, 1948:

follows: 32,700

104 per bands

immature

granulocyt.ic forms stea(hly lost

3 per cent.,
95 pea bands cent, 29

lymphocytes
erythrocytes, per cent,

57 per immature

basophils

cent.
10,300,

February
segmented!

leukocytes

granulocytie

per

cent,
The

lymphocytes
infant

20 per

bleeding,
later short. abdomen, were
*

which
was

had
associated

been

at birth,
a purulent

a persistent pulmonary infection still occurred on crying and

nasal infection. Deat.h The enlarged mesenteric side and occurred neck

develope(l.
exertion at was hut and and two three

Nasal
weeks

and Autopsy.

weeks.

A female virtually there in the (Ace. ant!

52 cm. bilateral mediastinal,

in length, mass talipes

weighed
filled varus. the

4025 Gm.
left Numerous

so abnormally tympanitic nodes discrete retroperitoneal Washingt.on,

as to be observed Case2

a large

of a distended

peril)ronchial, by I)r. H. 11. Leffler,

205756)

contributed

Provide!lce

Hospital,

D. C.

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992

CONGENITAL

LEUKEMIA

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From bloodjournal.hematologylibrary.org by guest on February 17, 2014. For personal use only.

WILLIAM

G.

BERNHARD,

IRA

GORE

AND

RALPI!

A.

KILBY

993

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From bloodjournal.hematologylibrary.org by guest on February 17, 2014. For personal use only.

994

CONGENITAL

LEUKEMIA

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WILLIAM

G.

BERNHARD,

IRA

GORE

AND

RALIH

A.

KILBY

995

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From bloodjournal.hematologylibrary.org by guest on February 17, 2014. For personal use only.

996
regions. metit 2011(1
of

CONGENITAL

LEUKEMIA

The of the
heart..

thymus liver, spleen

sas

visibly

etilarged

by

hemorrhage.

Cardiac
the for foramen a 3 week

(15 x 7 x 4 cm. and enlargement was entirely

ovale and
infant.

10 x 4 x 2 cm.,
muscular; arteriosus was
st

TIie,e was respectively;

there were (onsid!ered hyperplast no

coissiderable

elllarge-

weights
a!iomalies, within ic :o!i(I the

not

given)
of

Pate!icies li!liits
cvt ol

both

the botse

d!uctus niarrow

beitg rikingly

!lor!nal character

old

.ficroscopic

examination..

The consistitig

itS

ogic very
toeoh-

uniform, itfilt.rat.es enlarge!11ent the other

of poorly

(iifferentiated! in Less

locytic series. few . Ixt.e!isive

counted served Case iti for

Erythropoiesis
of viscera. these

was
of leukemic

considerably
cells organs.

the

reduced hea,t

and and
,

prinitive cells megakarvocvtes

bodIes. of liver similar

of the

graIn!-

were
:111(1 spleen cells were

lti,pl (lel)osits

extetisive

3, AFIP

Accession

term uncomplicated! of various sizes were

189595. A white male i!ifatit. l)orn February 19, 1947, after a full pregnancy, weighed! 4,082 Gm. at birth. A !lun3bet of cutaneous lumps noted tot once. Serologic examinatioti of the maternal blood was isega-

FIG.

1.-Case

1.

AFIP

Neg.

280588-1,

2.

Low

(205

X)

of the liver. histologically.

magnification.

So intensive is the leukemic A fair degree of granulocytic

infiltrate that differentiatio!1

and! high (435 X) magnificatiotis it is dlifficult to idetitify the orga!I is to be ol)serve(I in the higher

tive.

The

mothers

blood Twenty-four

cells

contained hours after

the birth

Rh

factor, the

as did

the

itifatit

s blood!

whets

teste(1 it. was

subsequently.

noteti that the vomitus contained appreciable (outit at this time was report.ed t.o be 280,000. Upon examination on the second day of life the i!ifant tlid not. appeal to 1)e acutely ill. Hard masses, varvi!3g from 1 to 2 cm. in diameter, attached! to skits but not to u!!(lerlying tissue, were palI)able its the subcutaneous tissue. The overlyi!ig skin varied! from reddish to purplish in color, the largest masses having a central area of purplish violet color surrounded by a thin ring of blue. There were many other discolored areas on t he skin, approximately 1 mno. in diameter, which were deep blue with no underlyitg mass. F:xanitiat.iot of head a!sd neck, thorax and lungs oas negative. The heart was !sot etilarged to percussion and! no murnours were heard!, although t.he heart soundis at the apex were of a I)ecUlia! rough character;
the below
rate was

infatit quantities

vomited after feediing and of 1)100(1. Total leukocyte

120

per margin

minute

and

the

rhythm across

regular. t.he midline

The to

liver, the left

which

was

palpable line,

7 c!n. filled

the

costal

amid! extended

midclavicular

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WILLIAM

G.

BERNHARD,

IRA

GORE

AND

RALPh

A.

KILBY

997
t he costal No ratio. lynophi oIost i!ifUSid)!I

to large

1)art
.

of the

tol)(ld)Ifle!1.

1hoe

spleen

was 4 cm.

e!ilarge(I, lotig tO!ld

bei!lg wtos glucose tot first i!sfto!it

wtts

PalI)tible

4 dl. riot cent) ground

to

below Oozi!lg. in 1/1

!i1ttrgiti tlO(le

The

dd)!dl was was were st reaked l)lttced

a))roxi!ooately I)hlysical
0!1 a fornula

dry
rioted. (5 coffee

a!i(I

etiltorgemetit
i!Iftttlt lie

or further
vO!flite(1 with

abnormalities
of anligels

were a!id The

The
of t late,

feedings Iscatsie

PrOtflPtl; bright red!

the blood.

vonoitus,

in appettra!lce, solution

give!i a physiologic tarry rttpid ible

subcutaneous toaterial On

of l6
cblo!idc.
tlOO!l

niolar
The of

sotIiuts
stools 21
to

lactate
regultorly
,

:01(1 glucose
co!ltained i!lfatit At
t

(2.5
bright

ier

cent)
red becttnoe
,

in tnore

of sO(!iuflo
.

blood

antI

the atl(I

afterhe was
t o 1e

lbrutoii ti
ton oxygen

t he
tit
.

s iespirtitions

tt!i(I

Itobored

1)1tI(e(I
not nou!lcp(l
J:rt

te
Short

icdal)le,

a!ld (lett(1
yes cent,

7 : 30 P .\1 . , Feb rua ry 23 i!ile later t he Pulse becatue

tofter

respi rat i otis

ifl1l)e!del)t wit hi blasts 2 per

we re so
.

sI i ght tos not The inftttit. tts

de!it

pro-

seven

days novelocytes

l)irth.
; leukocytes cetit, l98,(X.X), I 5 l)CF
,

hiroct

!sun1l)ere(I

4 ,20(),()()0 5 per

progra!IulO-

cytes

16 p-r

metamyelocytes

cent,

1)andS

per

tetit

fila-

Fw. of t he

2.-Case bone 4 pr marrow

2.

AFIP illust lymphocytes

Neg.
rat itig

205756-1, t he S per

7. Low

(205
a!id

X)

and
u!,differe!it P#{176} cent,
.

high

(435
iated erythroblasts time

X)

magnifications

homoge!leous cent, for!ns One

to

cellular

growth. per cent, and

Illoti on.

ments normoldast.s and 1 otu bent Ure(I over heart, !Iodular i nt

est

ce!it,
5 p ln,!lct

snoudges 1 er of oh )t toi
!l

38 cent the
!nat

cent time

a!s(I was u re skull was

utsidetit five
alit!

ified minutes.

Bleeditig skits

was was

fifteen

minutes

prot.hrombin marrow ge!logrtoms .1 ulops!/. A well

large

nodules

removed

performed

e rial

for

ptot hol ogic

exami

of

lo!ig newborn
i!i

bo!ieS

were white

negative.

developed,

male
firtn gray !ial weighing several

of 7 days,

weighed
iO!IS

51 .5 (til. in le!igth. its SIZP fross I ens. to 4.5 t he Liver

lI t

Nu!s1erous cm.. a!sd greatly 27.7 Gns., epicardium.

superficitol color from

ry

nodular elevat to purple a!sd Isodes 300 were a!1d lesiolis port mucosa, ion of 37.5

3600 Gm. totid neasof t lie skits, varying

were respectively. circumscribed, in a!1d the colon the small was lept.opresetit toscetiding Pelves tioted

hemorrhagic, Gm., poorly were t lie of

ire

I )ody
weighed
of

surf ace.
were the a!sd

Axi II a

atid

i !igui

enl torged.

:u!(I which

spleeti

e!ilarged, prese!sted Similar of the

The

grtty-yellow,

clevatiotis i tie and over bladder, t he I Ienorrhages

!iscrete
t

i nvolveme!st

lie

first i!,al

difTuse. !lie!ii!!ges

were
left
iO!5

l)rese!it

in

ititest for were could

t he reiial

cerebrum. of t lie lungs, :ol 1 gross

Lxcept t here cha!lges

discrete
!iO

e!iltorgenoent. positive cdl to

the

lymph
With the Process.

tiodes
except

and
ion

l:ot (by co!isolidat of 1) ronchop!ieumonia,

ot her be rel

findings. a leukemic

From bloodjournal.hematologylibrary.org by guest on February 17, 2014. For personal use only.

998
.Iicroscopic tive and poorly and the the was and identical tissues. e.rainination. differentiated megakaryocytes leukemic nodulmor
in

CONGENITAL

LEUKEMIA

The cells cellular lesions with

boIse were

nottrrofew. heart, bone

was Liver The marrow.

occupied series. sections spleeti Less tond

by were an(!

a utsiform Erythropoiesis scarcely lymph blto(ider tiodes

growth was were to be were recognizable,

of prinoiconsiderSO

of the infiltration. of skin, the

granulocytic

ably
intense involvet! masses in toll An

reduced

diffusely cellular l.)rese!st

intestine

proved dleposits

character

intensive

Case presentet! disturbance. observed intestinal

was

incidental 4, -IFIP

finding Accession

as

a smtoll
234151. A

(microscopic)
white male tobsent. the mucous spleen the stool

todrenal
infant,
who

rest

in
weighed

the

epidlid!vmis.

3005

Gm.

at

birth,,

dextrocardia Petechiae on the first was day bleeding

tonti bilatertolly of the skin, of fount!

was

radii, as well membrtone, was and palpably vomitus.

as evidence of hemtttologic ton(I the conjunctivtte were eislarged. l)ut the released lvidence episode from of gastro-

life. in

The both

apparently
Blood

trtonsitory.
count

difficulty. on

Ots the tenth day circumcision reported as tsormal tmnd the infatst

was
was

accomplished

of bleedi!sg without
the Isospit tol

the seventee!sth day. On the forty-secono! day of life the child, who exhibited only a slight gaits iii weight, was admitted to the hospital because of considerable bleeding from the rectum for the preceding three days. There was mtorked pallor; petechiae were observeo! oto the ptolate, and the child appeared! moribund. The liver was enlarged but the spleeti was not palpable. Blood count was: erythrocvtes 1,500,000; total leukocytes 12,000 to 17,000; platelets 80,000. Bleeding and clotting times were reported normal. Rectal bleediisg contitsued after two transfusions. On the sixty-eighth day of life the child was transferred to tonot her hospital,
where extensive and skin petechiae intestinal and bleeding ecchymoses continued. were Despite noted. Spleen multiple atsd liver were the found
inftont

to be enlarged

trtotssfusions,

died.
I

Peripheral

Blood

Counts

of

the

Last
-

Ten

I)ays

Date

______
(Millions)
Hgb WBC P L

I M

Bleeding

Clotting

Platelets

4/12/48 4/13/48

2.47 3.75 1 3.6 2.9

50% 7.8 78% Gm.

.

13,500
I

42
I

51

6
1

I 230
415 I

4lO
340

None
see,, No!le see,,

9,800

12.2 4/14/48
4/15/48 4/16/48 68% 9.8 59%

Gm.
21,800 Gm. 5,600
I

35
30 21

64
55 74 1 3

1 14 1

630

535
I

None seen

4/22/18

5.36

9.2 Gm. 95%

14.8Gm.

18,750

2SS

3,40

16,050

Tests
factor had Autopsy.

of the

maternal

blood

for

syphilis

(luring

pregtsancy

had
i!lftotst.

been
tolready

negtitive.
beds

The
note(I

Bhi
0!!

not been ascertaitsed Dextroctirdia tond

in either bilateral

the
abseisce

mother
of

or the
the rtodii

had

physical intestinal the liver,

regions Microscopic

examinatiots. Petechiae tract and other serous 150 Gm.; of the spleen,
were large and prominelst. examination.

and ecchymotic hemorrhtoges were foulsd! in the ski!s, and mucous surfaces. Body weight was 3500 Gm.; t.htot of 13 Gm. The lymph nodes of the cervical and medlitostilial
was

There
cells and in small were to fairly

cotssiderahle the granulocytic were atsd in foci the of

though series exceedi lymph ervthropoiesis.

utsiforno and tigly tsodes, many

hyperplasia
were poorly

of tlse
dific in the

marrow.
ferentiated.

Nearly
There was The viscera

all of the
wtos reduced, conspicuous showed

of

rich
the

component
spleen

of eosinophilic

myelocytes;
scto rce. and

erythropoiesis
G ranulocyt topparent

was
liver.

considerably

megakaryocytes intravascular

metaplasia

From bloodjournal.hematologylibrary.org by guest on February 17, 2014. For personal use only.

WILLIAM

G.

BERNHARD,

IRA

GORE

AND

RALPH

A.

KILBY

999

DISCUSSION

It seems
j)lesent.ed

mote multiple

than leukemia

a coincidence developmental
that

that
with

3 of our
mongolism,
responsible

4 cases
and
for

of congenital
has 0l)selved

leukemia examples
therefore, a

anomalies.
factors

Farber4 the

of
basis

congenital
for

speculating

associated the
the

there

is,

latter
to Ingalls7

may sixth

also
the

have
crucial

l)een week

influential of fetal

in causing

blood

(!ys(raSia.

A((oldhng

developmental
f!equently
(ulminates it is

peliOdl
life. It

for
is his

the

production that the

there

of mongolism occasionally bone marow

was

is the

to the and

ninth less which

than
in

other that

opinion structures,
Although

(luring this period, sustains an injury

leukemia. same

interesting
the

all of the
period! of

other
embryonic

anomalies literature

only 1 case (Case I ) of mongolism, noted entailed damage at appiox(table only one 3). Of the 14 cases presented examinations have gone an associated in 11 inunrecorded. regarding
during

imately

development

of congenital anomaly, Sttui(es

At

leukemia hut to the the

recorded (ursory suspicion

in the reports that

led rate

of the postmortem a malformation might disturbances

0! some mtre From

any

such

obious leukemid of the

growth process various

lead!

to speculation
disorder

the
the

iresence morphogenesis
TA
BLE

of the

fundlamental

structures.
ia : ()bserred

the
00(1

a(cd)unt
Crucial

of (latworthy
I)eielopmental (.tose Case Case 1 1 1 Period

and

3.-(ongenital

Leukem

.1 nomalies

1olotigol Int.eratrial

ism Sept.al 1)efect

I
I

6t h-9t Is week
Sth-7ths lOth-l4tls week week

Agetsesis of Ear Klippel-Feil Syndlrorne I)extrocardia Absence of Radii Pat ent Intervent ricul

a r Sept

urn

....

9th week 5th week 6t1,-8th week 5t hs-7t I, week

Case 2 Coose 4
Case Cross3 4 (Case

1)

Andlerson-

it

appears

that

life,
we!c

between
presumably

the
anomalies

fifth

and
correlated

the dlisturbance fourteenth weeks.

with the period

must of

have fetal

Tabulated

occurred above
life

are

early in fetal some of the

which they

observed
Since

(luring
not seem appear

initiated.5
significant granulocytopoiesis

quantitatively

(1005
it. does the
not

until that
of

the
leu-

fourth
kemia

month could

of exist

intrauterine before that

life time.

(Wintrobe20), However,

likely at

relative

abundance

recog-

nizable indicates portion leukemic

thtonic

differentiation
of

in

the

leukemic

cells

found

in

the

tissues

autopsy

that the process must certainly have fetal life. Histologically, at. least. process in most
in the

been present. during an appreciable in this respect, the granulocytic the

only

of these
adult.

cases
The

counterpart.

of the
leukemias

observable
of

pait
children

of the
under

disease.

of the congenital variety resembles acute clinical course is a. measure Since Farber4 found that 98 per cent

of the

200), genital
literature few to

ten years of age were of the acute variety (196 of it would! appear fruitful to compare the process in newborns having conanomalies with that. in normally formed infants. The reports in the are inadlequate for such a study ant! the 4 cases in this study are too permit
cases

conclusions.
seem to

Most

have

offered

little

diagnostic

difficulty.

The

prevalent

use

From bloodjournal.hematologylibrary.org by guest on February 17, 2014. For personal use only.

1000 of serologic
erythroblastosis

CONGENITAL

LEUKEMIA

tests

for

syphilis minimized

and

the the

current problem

alertness that

to

the

factols earlier

producing

have

confronted

pathol-

ogists. In medullary proliferation

easy. In also architecture

these (OnditionS an(l also in sepsis a considerable amount hematopoiesis is to be observed. When theie is app!ecitohle of !eticulo-endothehal cells, distinction from leukemia
general,
of

of extraasSO(iate(!

may
the though

not
normal

be
this

however, such struct.uies

the
as

piocess liver,

in spleen

the

forme! an(l lymph

(onfo!ms nodes,

to and

may and
Accession

he

true

in leukemia, efface diagnosis but. was a life

actual normal of

tumorlike histologic he substantiated all of poorly reduced! congenital

aggregates
structures.

and! In

(olonies
Case

may,

often

(10, completely 234151) during

4 (AFIP was

thrombocytopenic by postmortem differentiated! and mega in thrombopenic repoited cases

purpura

entertained
tions.

Hematopoiesis

coultl not viitually was

observagranulocytic were purpura.14

of

charactei.

Erythropoiesis

considerably

kaiyocytes
congenital

almost absent, contrary to what. It is of academic interest that leukemia tionable leukemia. handicapped
matter, acute tions

would be expected all but 2 of the

weie of the granulocyt.ic variety. That. of White and! Bulns is quesan(! although incompletely studied possibly represents lymphocytic Later in childhood, classification of the usually acute leukemia is by the virtual absence of cellular differentiation. Zuelzer,2 for that
questions

the Nevertheless, the and

validity frequently children

which

of

attempts seem

to

distinguish
to

the
entertain

cell

type
some

in
reserva-

the

disease. regarding

it would stated are

might

appropriate

generalization lymphocytic.
contributed

that
to the

the
onset

majority
of the

of lenleukemic

kemias
Maternal

in infants
influences

have

process were not. apparent in this material. and since there are many reported cases leukemic women, the presence of a blood
appear to he of etiologic significance.
SUMMARY

None of the mothels of normal children dyscrasia in the

were leukemic, 1)orn to frankly

mother

does

not

Four acceptable
locytic

new
series

cases cases
were

of congenital in the literature.

males anomalies involved;

leukemia

reported 1
of

heie
these

may
(ases females

be added
cells
in a ratio

to

the granuof more

14

In all except
predominat.ed were present

of the we

over in

than

2 to

1.

Congenital

3 of

the

4 cases

have

reported,
usual reported similar to

indicating finding
here

a growth

disturbance

early

in

fetal anti
of

life.

Contrary
in the
respect

to

the
ate

in childhood exhibited
which

leukemia, cells of the granulocytic a fair degree of differentiation

characterize the chronic form

series

4 cases It seems

in this
disease.
portion

those

the

likely, uterine
1 2

therefore, life.

that

the

leukemia

existed REFERENCES

during

a significant

d)f intra-

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W.:

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Leuk#{228}mie. Ztschr.
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JR.

R. G.:
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S.:

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five

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WILLIAM

G.

BERNHARD,

IRA

GORE

AND

RALPH

A.

KILBY

1001
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